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Graber andWilbur’s

Fa mil y meDiCiNe
exa miNat io N
& Bo a r D r eview
Graber andWilbur’s
Fa mil y meDiCiNe
ex a miNa t io N
& Bo a r D r ev iew
Fo u r t h Ed it io n

Jas K. W lb , Md
Clinical Associate Professor
Department of Family Medicine
Roy J. and Lucille A. Carver College of Medicine
University of Iowa
Iowa City, Iowa

Ma k A. G abe , Md , MSh CE, FACEP

Clinical Professor
Departments of Family Medicine and Emergency Medicine
Roy J. and Lucille A. Carver College of Medicine
University of Iowa
Iowa City, Iowa

B g E. r ay, Md , MME
Faculty Associate Physician
Roy J. and Lucille A. Carver College of Medicine
University of Iowa
Iowa City, Iowa

New Yor /Chicago/San Francisco/Athens/London/Madrid/Me ico City

Milan/New Delhi/Singapore/Sydney/Toronto
Graber and Wilbur’s Family Medicine Examination & Board Review, Fourth Edition

Copyright © 2017 by McGraw-Hill Education. All rights reserved. Printed in China. Except as permitted under the United States Copyright Act
o 1976, no part o this publication may be reproduced or distributed in any orm or by any means, or stored in a data base or retrieval system,
without the prior written permission o the publisher.

Previous editions copyright © 2013, 2009, 2005 by he McGraw-Hill Companies, Inc.

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ISBN 978-1-259-58533-3
MHID 1-259-58533-6

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his book was set in Minion Pro by Aptara, Inc.

he editors were Amanda Fielding and Kim J. Davis.
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Library o Congress Cataloging-in-Publication Data

Names: Wilbur, Jason K., editor. | Graber, Mark A. (Mark Alan), editor. |
Ray, Brigit E., editor.
itle: Graber and Wilbur’s amily medicine examination & board review /
editors, Jason K. Wilbur, Mark A. Graber, Brigit E. Ray.
Other titles: Family practice examination and board review. | Family medicine
examination and board review
Description: Fourth edition. | New York : McGraw-Hill Education Medical,
[2017] | Preceded by Family practice examination and board review /
editors, Jason K. Wilbur, Mark A. Graber. 3rd ed. 2013. | Includes
bibliographical re erences and index.
Identi iers: LCCN 2016011464| ISBN 9781259585333 (pbk. : alk. paper) |
ISBN 1259585336 (pbk. : alk. paper) | ISBN 9781259589775 (ebook) |
ISBN 1259589773 (ebook)
Subjects: | MESH: Family Practice | Examination Questions
Classi ication: LCC R834.5 | NLM WB 18.2 | DDC 610.76–dc23 LC record available at

McGraw-Hill books are available at special quantity discounts to use as premiums and sales promotions, or or use in corporate training
programs. o contact a representative, please visit the Contact Us pages at www.mhpro essional.com.
To Russell and Aurelia Weil, who treated me with loving kindness rom
the moment they met me and have accepted me into their amily with
open arms.

To Eastern Virginia Medical School which, in a strange warp o

reality, actually admitted me despite my grades. And to the staf o the
Prescriber’s Letter, who have put up with me or all these years.

To my late Grandma Trudy and Grandpa Leon Rees who supported

me in my endeavors to become a physician and who made all things
possible by encouraging a well-rounded education.
Contributors........................................................................................... ix 15 Obstetrics and Women’s Health ......................................... 409
Preface ...................................................................................................xiii 16 Men’s Health .............................................................................. 454
AFew Words on Studying and Taking the Board Examination .....xv
17 Dermatology ............................................................................. 475
1 Emergency Medicine................................................................... 1 18 Neurology................................................................................... 498
2 Cardiology .....................................................................................40 19 Ophthalmology ........................................................................ 526
3 Pulmonology................................................................................97 20 Otolaryngology ........................................................................ 548
4 Allergy and Immunology ...................................................... 131 21 Care of the Older Patient ....................................................... 569
5 Nephrology ................................................................................ 140 22 Care of the Surgical Patient .................................................. 598
6 Hematology and Oncology.................................................. 173 23 Psychiatry ................................................................................... 626
7 Gastroenterology..................................................................... 200 24 Nutrition and Herbal Medicine ........................................... 660
8 Infectious Diseases .................................................................. 237 25 Substance Use Disorders ...................................................... 672
9 HIV/AIDS ..................................................................................... 258 26 Ethics ............................................................................................ 688
10 Endocrinology .......................................................................... 271 27 End-of-Life Care ........................................................................ 698
11 Rheumatology .......................................................................... 303 28 Evidence-Based Medicine .................................................... 712
12 Orthopedics and Sports Medicine .................................... 334 29 Patient-Centered Care ............................................................ 724
13 Pediatrics .................................................................................... 362 30 Final E amination .................................................................... 736
14 Adolescent Medicine .............................................................. 396
Index .....................................................................................................761

Vijay Aluri, MD David A. Bedell, MD
Rheumatology Fellow Clinical Associate Pro essor
Division o Immunology Department o Family Medicine
Department o Internal Medicine Roy J. and Lucille A. Carver College o Medicine
University o Iowa Hospital and Clinics University o Iowa
Iowa City, Iowa Iowa City, Iowa
11. Rheumatology 25. Substance Use Disorders

A. Ben Appenheimer, MD Julia Buchkina, MD, MPH

Fellow Physician Upstream Functional Medicine
Department o In ectious Diseases Iowa City, Iowa
Roy J. and Lucille A. Carver College o Medicine 24. Nutrition and Herbal Medicine
University o Iowa
Iowa City, Iowa Chris Buresh, MD, MPH, FAAP, FACEP
9. HIV/AIDS Associate Pro essor
Department o Emergency Medicine
Stacey Appenheimer, MD University o Iowa
Clinical Assistant Pro essor Iowa City, Iowa
Department o Family Medicine 20. Otolaryngology
Roy J. and Lucille A. Carver College o Medicine
University o Iowa Nicholas R. Butler, MD, MBA
Iowa City, Iowa Clinical Assistant Pro essor
5. Nephrology Department o Family Medicine
Roy J. and Lucille A. Carver College
Olivia E. Bailey, MD, FACEP
o Medicine
Clinical Associate Pro essor
University o Iowa
Clerkship Director
Iowa City, Iowa
Department o Emergency Medicine
21. Care o the Older Patient
Roy J. and Lucille A. Carver College o Medicine
University o Iowa
Iowa City, Iowa Rachel R. Butler, MD
1. Emergency Medicine Pulmonary Critical Care Fellow
Department o Internal Medicine
David Baumgartner, MD, MBA Roy J. and Lucille A. Carver College
Resident Physician o Medicine
Department o Emergency Medicine University o Iowa
University o Iowa Healthcare Iowa City, Iowa
Iowa City, Iowa 3. Pulmonology
22. Care o the Surgical Patient
Meghan Connett, MD
Martin O. Bazelak, MD Clinical Assistant Pro essor
Fellow Physician Department o Family Medicine
Department o Internal Medicine and Hospice Roy J. and Lucille A. Carver College
and Palliative Medicine o Medicine
University o Iowa University o Iowa
Iowa City, Iowa Iowa City, Iowa
27. End-o -Li e Care 14. Adolescent Medicine

Elizabeth S. Cramer, MD Bharat Kumar, MD

Clinical Assistant Pro essor Rheumatology Fellow
Department o Family Medicine Allergy/Immunology Fellow
Roy J. and Lucille A. Carver College o Medicine Division o Immunology
University o Iowa Department o Internal Medicine
Iowa City, Iowa Roy J. and Lucille A. Carver College o Medicine
15. Obstetrics and Women’s Health University o Iowa
Iowa City, Iowa
Kimberly S. Delcour, DO 11. Rheumatology
Clinical Assistant Pro essor, Department
o Internal Medicine Ye-Jin Lee, MD
Division o Cardiovascular Disease, Fellow Physician
Interventional Cardiology Division o Gastroenterology/Hepatology
University o Iowa Heart & Vascular Clinic Department o Internal Medicine
University o Iowa Hospitals & Clinics Roy J. and Lucille A. Carver College o Medicine
Iowa City, Iowa University o Iowa
2. Cardiology Iowa City, Iowa
7. Gastroenterology
Nicholas Edwards, MD
Resident Physician Britt L. Marcussen, MD
Department o Emergency Medicine Clinical Associate Pro essor
University o Iowa Department o Family Medicine and Sports Medicine
Iowa City, Iowa Roy J. and Lucille A. Carver College o Medicine
12. Orthopedics and Sports Medicine University o Iowa
Iowa City, Iowa
Mark A. Graber, MD, MSHCE, FACEP 12. Orthopedics and Sports Medicine
Clinical Pro essor
Departments o Family Medicine and Emergency Medicine Denise A. Martinez, MD
Roy J. and Lucille A. Carver College o Medicine Clinical Assistant Pro essor
University o Iowa Department o Family Medicine
Iowa City, Iowa Assistant Dean
1. Emergency Medicine; 2. Cardiology; 7. Gastroenterology; O ce o Cultural A airs and Diversity Initiatives
26. Ethics; 28. Evidence-Based Medicine; 30. Final Examination Roy J. and Lucille A. Carver College o Medicine
University o Iowa
Erin R. Howe, MD Iowa City, Iowa
Clinical Assistant Pro essor 29. Patient-Centered Care
Stead Family Department o Pediatrics
Roy J. and Lucille A. Carver College o Medicine Ross E. Mathiasen, MD
University o Iowa Assistant Pro essor
Iowa City, Iowa Department o Emergency Medicine
13. Pediatrics Department o Orthopaedic Surgery
University o Nebraska Medical Center
Monika Jindal, MD Omaha, Nebraska
Chie Resident 12. Orthopedics and Sports Medicine
Departments o Family Medicine and Psychiatry
Roy J. and Lucille A. Carver College o Medicine Megan H. Noe, MD, MPH
University o Iowa Clinical Instructor
Iowa City, Iowa Department o Dermatology
23. Psychiatry University o Pennsylvania
Philadelphia, Pennsylvania
Brian R. Kirschling, OD, FAAO 17. Dermatology
Clinical Assistant Pro essor
Department o Ophthalmology and Visual Sciences Spriha Pavuluri, MD
Roy J. and Lucille A. Carver College o Medicine Neurology Resident
University o Iowa Hospitals and Clinics Department o Neurology
Iowa City VA Medical Center Roy J. and Lucille A. Carver College o Medicine
Iowa City, Iowa University o Iowa
19. Ophthalmology Iowa City, Iowa
18. Neurology

Brigit E. Ray, MD, MME Jack . Stapleton, MD

Faculty Associate Physician Pro essor
Department o Family Medicine Departments o Internal Medicine and Microbiology
Roy J. and Lucille A. Carver College Director, Helen C. Levitt Center or Viral Pathogenesis
o Medicine Roy J. and Lucille A. Carver College o Medicine
University o Iowa University o Iowa
Iowa City, IA Iowa City, Iowa
15. Obstetrics and Women’s Health; 22. Care o the 9. HIV/AIDS
Surgical Patient; 30. Final Examination
Rebecca uetken, MD, PhD
Sandra R. Rosen eld-O’ ool, MD Clinical Associate Pro essor
Clinical Assistant Pro essor Department o Internal Medicine, Division o Immunology
Department o Family Medicine Roy J. and Lucille A. Carver College o Medicine
Roy J. and Lucille A. Carver College o Medicine University o Iowa
University o Iowa Iowa City, Iowa
Iowa City, Iowa 11. Rheumatology
15. Obstetrics and Women’s Health
Jon N. Van Heukelom, MD
Margo Schilling, MD Clinical Associate Pro essor
Clinical Pro essor Department o Emergency Medicine
Department o Internal Medicine Roy J. and Lucille A. Carver College o Medicine
Roy J. and Lucille A. Carver College o Medicine University o Iowa
University o Iowa Iowa City, Iowa
Iowa City, Iowa 12. Orthopedics and Sports Medicine
8. In ectious Diseases
Karolyn A. Wanat, MD
Adam B. Schlichting, MD, MPH Assistant Pro essor
Clinical Assistant Pro essor Associate Program Director
Department o Emergency Medicine Department o Dermatology, Pathology, In ectious Diseases
Department o Internal Medicine University o Iowa
Division o Pulmonary, Critical Care and Iowa City, Iowa
Occupational Medicine 17. Dermatology
Roy J. and Lucille A. Carver College o Medicine
University o Iowa Michelle . Weckmann, MD, MS
Iowa City, Iowa Assistant Pro essor
1. Emergency Medicine Departments o Family Medicine, Psychiatry, and
Palliative Medicine
Victoria J. A. Sharp, MD, MBA Roy J. and Lucille A. Carver College o Medicine
Clinical Pro essor o Urology and Family Medicine University o Iowa
Roy J. and Lucille A. Carver College o Medicine Iowa City, Iowa
University o Iowa 27. End-o -Li e Care
Iowa City, Iowa
16. Men’s Health Natasha B. Wheaton, MD
Clinical Assistant Pro essor
Wendy Shen, MD, PhD Department o Emergency Medicine
Clinical Associate Pro essor Roy J. and Lucille A. Carver College o Medicine
Department o Family Medicine University o Iowa
Roy J. and Lucille A. Carver College o Medicine Iowa City, Iowa
University o Iowa 22. Care o the Surgical Patient
Iowa City, Iowa
4. Allergy and Immunology; 6. Hematology and Oncology Jason K. Wilbur, MD
Clinical Associate Pro essor
Brian X. Shian, MD Department o Family Medicine
Clinical Assistant Pro essor Roy J. and Lucille A. Carver College o Medicine
Department o Family Medicine University o Iowa
Roy J. and Lucille A. Carver College o Medicine Iowa City, Iowa
University o Iowa 4. Allergy and Immunology;
Iowa City, Iowa 5. Nephrology; 6. Hematology and Oncology; 16. Men’s Health;
10. Endocrinology 21. Care o the Older Patient; 30. Final Examination
Welcome to the ourth edition! We hope that you are as excited o er help ul suggestions. Likewise, the comments posted online
to be here as we are. First, let’s start with a quick tour o the (not usually the place one goes or a rmation) have been mostly
book. You will notice some new things as well as amiliar aspects approving, constructive, and enthusiastic.
rom the previous editions. What has changed? In order to keep T e rst edition was published amid a less-than- riendly
up with the times, we have altered the title slightly to Graber & environment, with declining interest in print media and several
Wilbur’s Family Medicine Examination & Board Review. Okay, well-known board review books already on the market. Because
big deal. But wait; there’s more. In addition, you will see a new our book carried a di erent tone, readers slowly gravitated to it,
and attractive layout. T e whole book is in color, so you do not and its market share grew by word-o -mouth. As o 2015, the
have to ip to the glossy pages in the middle o the book to see third edition was the best-selling board review book in print
the color versions o photos and gures. For those o you who and made Amazon’s top 10 list o general medicine books. o
love your e-readers and tablets, there is now an online version what do we attribute this success? Engaged and supportive read-
o the book complete with explanations or the Final Examina- ers play a huge role!
tion questions. We added 50 more questions to the last chapter, In preparation or work on the ourth edition, we saved all o
“Final Examination.” Each chapter now ends with a list o quick your emails and scoured the Internet or reader comments and
clinical pearls, which amount to several evidence-based one-liners reviews. We read and considered all that we could nd—which
per chapter to help consolidate high-yield in ormation. O course, amounted to several hundred readers’ ideas. So, you, the reader,
we have updated everything, so that you will have the most recent have helped shape this book. Keep those emails coming!
medical in ormation. Last but not least, we have a new editor, Brigit With all o the board review books out there, why should you
Ray, who has brought a resh perspective to the book. choose our text? T ere are two crucial dif erences between this
What has not changed? Our essential style remains the same. book and other board review books on the market. First, we
T e book is divided into 29 chapters based on body system and have written this book not only to help you pass the boards but
elements o patient care, ollowed by the “Final Examination” also to broaden your knowledge o amily medicine. T e major-
(chapter 30). T e thousands o questions in the book are woven ity o questions contain a detailed explanation not only o why
into cases, which we hope you will nd interesting, practical, an answer is right but also why the other answers are wrong.
and relevant. o test your acquisition o knowledge, each case In the rapidly changing world o medical knowledge, we have
ends with the learning objectives. o break the monotony o endeavored to provide you with the most relevant and up-to-
slogging through a study guide, you will nd “Quick Quizzes” date evidence. When the current evidence is controversial and
and “Help ul ips” peppered throughout each chapter. we are not certain what the American Board o Family Medicine
A dozen years ago when we wrote the rst edition, we made (ABFM) will do with it, we acknowledge the uncertainty and try
the decision to use the second person voice in order to engage to help you navigate the current evidence.
the reader better and to give the book a conversational appeal. We have tried to make this book as broad and as compre-
We have tried to keep the book rom being boring. Yes, we are hensive as possible. In addition to its use as a board review
aware that this is a study aid. But why must studying be an exer- book or amily medicine, it can be employed as a general
cise in tedium and endurance? It should be enjoyable, appli- review or primary care physicians, physician assistants, and
cable to real li e and provide a surprise every now and again. nurse practitioners. Students and residents studying or Step
You will nd (sometimes eeble) attempts at humor throughout 3 o the licensing examination should ind the book help ul
the book. We have noticed that an occasional reader does not as well. However, no board review book can possibly cover
appreciate our sense o humor. Well, we’re doctors, not writers the entire scope o amily medicine. Use these questions as a
or Saturday Night Live (but i Lorne Michaels is reading this— guide: what areas are your strengths and what do you need
give Jason a call). to study urther? Each answer o the “Final Examination” is
We have been impressed with the level o engagement our re erenced in the book so you can go back and review any
readers possess. Over the years, we have received scores o emails topic that you might have missed. For the online version, we
rom readers who have thanked us, corrected us, and sometimes realize it may be hard to switch back and orth through the
chided us. No matter the intent o the message, the tone is almost book so we have included the answer explanations in a sec-
universally positive—readers are invested in the book and want to tion or you.

In this book, the use o eponymous medical terms such as must acknowledge that the book would never get nished with-
Crohn disease and Wilson disease, re ects the current Ameri- out large amounts o co ee; so, he thanks everyone involved
can Medical Association recommendations or these and simi- in the worldwide production o co ee, rom the pickers on the
lar terms where the possessive orm is dropped. In addition, Central American ncas to the local baristas.
there is a general trend toward using ewer eponyms, such as Mark would like to thank Jason and Brigit; this has been a
Wegener, which has been dropped completely. We have made collaborative e ort, which has made it easier or all o us. T anks
note o both new and old terms when we have deemed the old to you or buying this book. T anks also to his amily: Hetty,
term more recognizable. Rachel, and Abe (as always). But not to the dogs, Nietzsche and
We enjoyed writing this book and we hope that you enjoy using Dante. T ey need to learn to stay either in or out o the house.
it. I you have suggestions or complaints (okay, maybe all o our No more o this back and orth. Music that has kept him awake:
jokes aren’t politically correct or even unny), do not hesitate to Faith No More, the Beach Boys (actually amazingly good . . .
write us at jason-wilbur@uiowa.edu or mark-graber@uiowa.edu. check out “T e Sounds o Summer: T e Very Best o the Beach
We take your comments seriously as we endeavor to make studying Boys”), and the Kinks. Finally, thanks to his bicycle or keeping
or the board examination more e ective and more un. him sane . . . although some would argue this point.
We acknowledge and thank all our chapter authors who have Brigit has been using the Family Medicine Board Review text
brought their expertise to bear on this project. We also want to study or years and thanks Jason and Mark or including her
to thank the good people at McGraw-Hill who have edited the as a new editor in this project! T is was an honor or her and
book to keep errors to a minimum and created a handsome and she enjoyed working on their team. Foremost, she would like
readable layout. to thank her ance, Austin, and her amily or being so patient
Jason thanks his loving and supportive amily. Af er some when she has been cranky and sleep deprived juggling every-
initial threats, Deb has granted her patience and understanding thing. It’s not easy juggling a master’s degree program with clini-
to the project, and Jason simply owes her dinner every night . . . cal duties, two busy schedules in the medical pro ession, and
or a year. Jason thanks his boys, Ken and ed, who o er a great long distance relationships! In act, she eels she is getting the
distraction rom work and nd it entertaining that their dad is hang o juggling so much that she may start to study how to
some orm o an author. Finally, as with every edition, Jason actually do it!
AFewWords on Studying and
Taking the Board Examination
T roughout the book, you will nd that we give advice on what Next, know what is on the examination. T e percentage o
we think is likely to be on the examination. T at’s what you’re examination content devoted to various systems is posted on
paying or, right? However, in previous editions, we have not the ABFM website, and we recommend you review it. T e top
advised readers on study habits or test-taking strategies. Here, systems tested are usually cardiovascular, respiratory, and mus-
we o er our humble suggestions on how to prepare or the culoskeletal systems. I you are weak in any o these areas, be
examination and enhance your overall per ormance. We rec- certain to ocus your studying on them.
ommend you read this section prior to diving into the meat o Now, what material should you use when studying? Some o
the book. our readers have been overly kind, suggesting in their reviews
While we acknowledge that some people are simply better test that this book is the only study tool needed or the board exami-
takers than others, there is good evidence to show that anyone can nation. While we would like to believe it, we cannot endorse this
improve his or her scores. In act, examination scores are directly point o view.
proportional to time spent studying or the examination (although o get a avor or the questions on the examination, the best
this association grows weaker or those who have high scores strategy is to go to the source. T e ABFM posts its In- raining
already). T e point is, you don’t have to be a genius who got a 36 on Exams (I E) or the last 3 years on its website (www.theab m.
the AC in order to rock the ABFM Certi cation/Recerti cation org). A login is required, which board-certi ed amily physi-
Examination. But you may need to put in the work. cians should all have. T e I Es are perhaps the best source
Your rst step in studying or the examination—af er pur- or assessing your knowledge—we strongly recommend you
chasing this book, o course—should be to develop a study use them. Although we do not recommend relying on the I Es
plan. Plotting out time and dedicating that time to uninter- as your only study aid (obviously; we’re trying to sell books
rupted study is important. How much time do you have be ore here!), you can use these as a way to measure your progress as
the examination? How many hours per week can you devote to you study. T e critiques are available as well, so you can learn
studying? When are you most productive in your studying— what the ABFM thinks you should know. T e ABFM also has
morning or night? What are the chances o a worldwide ailure extensive in ormation on what you should expect when you sit
o co ee crops? Will a new Star Wars movie open be ore the or the certi ying/recerti ying examination, including a tutorial
examination? T inking through these questions, get a calendar, that simulates the examination. I you are an anxious test-taker,
mark the examination date, and plot out days and times that be certain to check out the tutorial. While the ABFM has sev-
you will devote to studying. I you have taken the examination eral use ul tools, be aware that the Sel -Assessment Modules are
be ore and it didn’t turn out so well, you may need to change not representative o the types o questions you will nd on the
your daily work schedule or 2 to 3 months be ore the exami- certi ying/recerti ying examination.
nation to accommodate studying 10 to 15 hours per week. We Another great source or questions is the American Academy
endorse neither “cramming” or the examination nor “adding o Family Physicians (AAFP) website. I you are a member o
on” studying to an already ull schedule. o get the most out o AAFP, you can access questions or ree. T ey are categorized by
studying, you need to approach it like a daily devotion. body system and can be done in chunks o ten at a time worth
In order to maximize your return on your studying and to 0.25 CME credits. T is question bank o ers another opportu-
ocus on de ciencies, try taking a pre-test. T e best pre-test is nity to test your knowledge and determine where you need to
the ABFM I E (keep reading or more on this). You can use ocus your studying.
your results on the pre-test to see what areas are your weakest. Also, the AAFP markets a comprehensive board review sel -
Studying weak areas is less un but will net higher yield results study course, which will set you back about $1,000 i you are a
than studying areas o relative strength. I your practice is nar- member and more i you are not. Indeed, it covers everything
row in scope (e.g., a hospitalist), you probably already have a you need to know or the examination. But so does this book!
sense o areas o strength and weakness. Make sure you address So, the choice is yours, but we doubt that you will need both our
your weak areas with relatively more time on them. book and the AAFP board examination sel -study package.

What about texts and primary sources? Well, while we would In the past, the ABFM recommended relying on evidence in
admire your perseverance in slogging through whole texts prepar- place up to 2 years be ore the examination rather than the most
ing or the examination, we do not recommend attempting to read recent medical evidence. Now, the ABFM recommends exam-
cover-to-cover texts like Robert Rakel’s Textbook o Family Medi- inees rely on the most up-to-date evidence available. So, when
cine or re erence material like UpToDate. Don’t get us wrong. We you are looking at a question and thinking, “Well, the answer
like these sources and recommend them to you as re erences as you last year might have been ‘A’ but now the evidence points to ‘B’.”
are studying, but you should not rely on them as your sole study Choose “B.”
material. Likewise, using primary sources, like medical journals, is Success ul test-takers do not use grand strategies to outsmart
impractical as a study oundation but use ul to expand your knowl- the question writers; instead they tend to employ a ew simple
edge when you don’t understand something. rules when answering multiple-choice questions. T ese simple
As ar as board review courses: to each his own. I you are rules that ollow amount to guidelines that cannot be blindly
considering attending a course, the AAFP o ers comprehensive applied to the entire test but are of en true. No secret to many o
courses multiple times per year in locations all across the coun- you, perhaps, but here they are:
try. For-pro t entities provide additional options. I you learn • Go with your rst thought ul choice unless you have a solid
best in a live lecture setting, these courses may be a good option
reason to change it (e.g., you misread the question).
or you, but you need not attend a course to get all that in orma- • Look or catch words in the answers, such as “always” and
tion (c’mon—you’ve got this book!).
“never.” T ese will of en be incorrect.
T ere are some important basic things you need to know • Avoid answers with un amiliar terms (e.g., obscure disease
about the examination. First, the examination is composed o
names or rarely per ormed procedures). T ese are of en
our sections, two o which are general in nature and two o
which are modules that you will select on the day o the exami- • T e most detailed answer is of en the correct answer.
nation. It is best to choose modules with which you are more • I two answers are similar, they are probably both wrong.
amiliar. For example, i you practice primarily in an emer- • Stick with amily medicine principles (e.g., answers with
gency department, you may want to choose Emergent/Urgent
“more history” or “shared decision making” are more likely
Care and Hospital Medicine rather than Maternity Care (unless
to be correct).
you’re looking or the additional challenge). • I you don’t know, guess and move on. Do not waste time
T e examination consists entirely o our-item multiple-
deliberating on a single question.
choice questions. You are not penalized or guessing. An unan-
swered question will always be wrong; whereas, a guessed Finally, we part o ering advice that we know busy doctors
question has a 25% chance o being right. I you have no idea, seldom ollow: get plenty o rest. Seriously! Be prepared or
go ahead and guess. As a corollary to that rule, never exit the the examination day by getting a good night’s sleep. Don’t stop
examination without rst completing all the items. You cannot taking care o your health prior to the examination, and that
return to answer unmarked items. includes rest. Eat a good break ast, bring a snack or your breaks
Read every stem and option care ully. Although we doubt and plan to take yoursel out or a nice lunch (but skip the mar-
that the ABFM writes “trick questions,” they do use catch tini—you’ve got an examination to nish). Just like a mountain
words/phrases, such as “except,” “most likely,” “ rst step,” and climber, wear layers. Some o those test-taking centers are reez-
“least likely.” I you are not attending to the catch phrase, you are ing; some are boiling. Stay positive, take a deep breath and keep
likely to answer the question wrong. moving through it. You will pass this thing! Good luck.
Adam B. Schlichting, Olivia E. Bailey, and Mark A. Graber
Question 1.1.2 Which o the ollowing statements is true
CASE 1.1 about gastric lavage?
You get a call rom a panicked mother because her 4-year-old A) Exce t in extr ordin ry circu st nces it should only be
took some o her theophylline. She thinks it may have been as done in the rst hour er n overdose.
many as 10 pills but is not clear on the actual number. She is B) P tients who h ve h d g stric l v ge h ve higher incidence
about 35 minutes rom the hospital. o ul on ry s ir tion th n tients who h ve not.
C) P tients who undergo g stric l v ge h ve higher incidence
Question 1.1.1 Your advice to her is: o eso h ge l er or tion.
A) Give i ec c to ro ote sto ch e tying nd reduce D) It c n ush ill r g ents beyond the ylorus.
theo hylline bsor tion. E) All o the bove re true.
B) Do not give i ec c nd roceed directly to the hos it l.
C) C ll oison control nd then roceed to the hos it l. Answer 1.1.2 The correct answer is “E.” All o the o tions re
D) Bre the dee ly nd c l down; theo hylline is h r less. true. Gener lly, the e c cy o g stric l v ge is li ited. Out-
co e d t do not su ort the use o g stric l v ge er the rst
Answer 1.1.1 The correct answer is “B.” Do not give i ec c hour. In rticul rly severe overdose or in n overdose th t is
but roceed to the hos it l. “A” is incorrect or cou le o likely to del y g stric e tying (e.g., tricyclic ntide ress nts),
re sons. First, i ec c is not rticul rly e ective ethod o you ight w nt to consider l v ge, but such circu st nces re
e tying g stric contents. More i ort ntly, i the tient unusu l. G stric l v ge incre ses the risk o s ir tion, eso h-
should st rt to seize while vo iting s result o the i ec c, ge l er or tion, nd c n ush ill r g ents beyond the
she could s ir te the vo itus c using n s ir tion neu o- ylorus.
nitis. “C” is incorrect bec use you do not w nt to del y de ni-
tive tre t ent. You c n c ll oison control while the tient is Question 1.1.3 A ter care ul consideration, you decided not
on the w y. to lavage. She is now 55 minutes a ter the ingestion. The next
best step to take in this patient is to:
A) Check blood theo hylline levels nd re er or he odi lysis
HELPFUL TIP: i rkedly elev ted.
Ipecac is ine ective and possibly harm ul. It causes my- B) Ad inister 1 g/kg o ch rco l with sorbitol.
opathy and cardiac problems when used chronically C) Pro hyl ctic lly tre t this tient or seizures using lor z-
(such as in those with anorexia nervosa). The Food and e .
Drug Administration (FDA) has considered making ip- D) Pro hyl ctic lly tre t this tient or seizures using henyt-
ecac available by prescription only, and many pharma- oin.
cies currently do not stock it. E) C ll the Child Li e Activities T er ist to distr ct the child
while you settle in or 4-hour observ tion eriod.

T e patient arrives in your emergency department (ED). Answer 1.1.3 The correct answer is “B.” Giving ch rco l is
She is alert but with a tachycardia o 160 beats per minute likely hel ul only within the rst hour af er ingestion. “A” is
and a stable blood pressure (BP). T e ingestion occurred incorrect bec use the tient’s situ tion could deterior te by
about 50 minutes ago. You contemplate gastrointestinal (GI) the ti e blood levels return. “C” nd “D” re incorrect bec use
decontamination. seizure ro hyl xis is not indic ted in this tient. Although

seizures re jor ni est tion o theo hylline toxicity,

they re ore likely to occur in tients who t ke theo hylline QUICK QUIZ: BIOTERRORISM
chronic lly nd h ve toxic blood levels. Acute ingestions re less
worriso e. Observ tion lone (“E”) is not the best choice here. Oh no. Godzill is tt cking okyo. And this ti e it is with
we ons o ss destruction. Which o the ollowing ro erly
describes the isol tion require ents o tient with ul o-
Although requently given, single dose activated char-
n ry nthr x?
coal has limited or no e ect on outcomes. It reduces
A) No isol tion necess ry. T e tient y be in the s e roo
absorption by about 30% i given within 1 hour o in-
with n unin ected tient.
gestion and likely has no bene it a ter 1 hour. It can also
B) Res ir tory isol tion only.
cause vomiting with aspiration. For this reason, it has
C) Res ir tory nd cont ct isol tion.
allen out o avor (I don’t remember the last time I used
D) Neg tive ressure roo (such s with tuberculosis) + cont ct
it in our ED [MG]). We are not sure what the correct an-
isol tion.
swer on the test will be . . .
The correct answer is “A.” Pul on ry nthr x is not tr ns it-
ted erson to erson. Cont ct isol tion is indic ted in those
with cut neous nthr x nd GI nthr x (where di rrhe y
be in ectious).
Do NOT give activated charcoal to patients with an
altered mental status or who are otherwise unable to
Godzill is not done yet . . . Which o the ollowing drugs should
protect their airway. To prevent aspiration, do not give
be used s ro hyl xis g inst inh led nthr x should ex osure
charcoal to a patient likely to have a seizure (such as
to erosolized s ores be docu ented?
with tricyclic overdose).
A) A rst-gener tion ce h los orin.
B) ri etho ri /sul ethox zole.
C) Ci ro ox cin.
Question 1.1.4 For which o these overdoses is charcoal D) A third-gener tion ce h los orin.
NOT indicated?
A) Acet ino hen. The correct answer is “C.” Fluoroquinolones re the drugs o
B) As irin. choice when tre ting those ex osed to nthr x. Doxycycline
C) Iron. y lso be used. Ce h los orins nd MP/SMX re not ctive
D) Digoxin. g inst nthr x.
E) O i tes.
Godzill , rustr ted by his iled nthr x tt ck, is now s re d-
Answer 1.1.4 The correct answer is “C.” Ch rco l will not bind ing s ll ox. Which o the ollowing is NO true bout s ll-
iron. Ch rco l will lso not bind C ustics/corrosives, He vy ox?
et ls, Alcohols, R id-onset cy nide, Chlorine (or iodine), A) Isol tion is best done t ho e i ossible.
Other insoluble t blets, Ali h tics (hydroc rbons), or L x tives B) T e tient is in ectious until he or she beco es ebrile.
(mnemonic: CHARCOAL). So e o you y h ve nswered C) All lesions re gener lly in the s e st ge o evolution,
“A.” T eoretic lly, ch rco l could inter ere with the ction o unlike wh t is seen in v ricell .
N- cetylcysteine, the ntidote or cet ino hen ingestion by D) S ll ox i uniz tion c uses n ence h litis in 1:300,000
bsorbing it. However, this is ore o theoretic l concern th n o which 25% o c ses re t l.
n ctu l one. First, the drugs should be used t di erent ti es.
Ch rco l should be given i edi tely, while N- cetylcysteine is The correct answer is “B.” T e tient is in ectious until ll le-
given only er 4-hour levels re v il ble. Second, the doses o sions crust over nd in ectivity h s nothing to do with the res-
N- cetylcysteine reco ended re quite high, nd you c n give ence or bsence o ever. “A” is true. Isol tion is best done t
higher dose i you will be using it with ch rco l. Fin lly, intr - ho e since this will li it s re d (those in the household h ve
venous (IV) N- cetylcysteine is v il ble nd is obviously not likely lre dy been ex osed). “C” is lso true; ll lesions re in
ected by ch rco l. “B,” “D,” nd “E” re ll incorrect. While we si il r st te o evolution. Fin lly, “D” is true nd is the re son
do h ve ntidotes or digoxin nd o i tes (Digibind, n loxone), we do not currently i unize g inst s ll ox—well, th t nd
ch rco l is still indic ted to reduce bsor tion within the rst the ct we er dic ted it (W y to go, hu ns!).
Objectives: Did you learn to . . .
• Manage a patient with an acute ingestion?
CASE 1.2
• Describe the appropriate use o gastric lavage and charcoal A 22-year-old emale presents to the ED with an overdose.
administration? She has a history o depression, and there were empty bottles
• Identi y situations where charcoal may not be indicated? ound at her bedside. T e bottles had contained clonazepam

and nortriptyline. T e patient is unconscious with dimin-

ished breathing and is unable to protect her airway. You notice that the patient begins to have an abnormal trac-
ing on the cardiac monitor, so you order an ECG.
Question 1.2.1 The BEST next step is to:
A) Intub te the tient. Question 1.2.2 Which o the ollowing ndings would you
B) Begin g stric l v ge nd d inister ch rco l. expect to nd in a tricyclic overdose?
C) Ad inister u zenil, benzodi ze ine nt gonist, to w ken A) Nor l QRS co lex.
her nd i rove her res ir tions. B) Second- nd third-degree he rt block.
D) Ad inister bic rbon te. C) Widened QRS co lex.
E) Ad inister li id e ulsion. D) Sinus t chyc rdi .
E) Any o the bove.
Answer 1.2.1 The correct answer is “A.” T is tient should
be intub ted. Re e ber in ny e ergency situ tion th t the Answer 1.2.2 The correct answer is “E.” All o the bove nd-
ABCs ( irw y, bre thing, nd circul tion) re the riority. “B” ings c n be seen with tricyclic overdose. In ct, the ost co -
is incorrect bec use, s noted e rlier, tients who undergo g s- on resenting rhyth is n rrow-co lex sinus t chyc rdi .
tric l v ge h ve higher incidence o ul on ry s ir tion— n As toxicity rogresses, you c n see rolonged PR interv l,
even gre ter concern in the obtunded tient. In ct, irw y widened QRS co lex, nd rolonged Q interv l. A QRS
rotection is MANDA ORY be ore undert king l v ge. “C” is >100 s is redictive o seizures nd QRS >160 s is highly
incorrect. Flu zenil will reverse the benzodi ze ine. However, redictive o ventricul r rrhyth i in tients with tricyclic
we know ro ex erience th t seizures in tients who h ve ntide ress nt overdose. He rt blocks (second nd third degree)
h d u zenil re rticul rly di cult to control. T is would her ld oor outco e nd y be seen l te in the course. Asys-
be rticul rly roble tic in tient with ixed overdose, tole is not ri ry rhyth in tricyclic overdose nd tends to
such s with tricyclic, where seizures re co on. T us, it is re ect the end st ge o nother rrhyth i .
reco ended th t u zenil be used only s revers l gent
er rocedur l sed tion in tients who re not on chronic YIKES!! T e patient becomes unresponsive and you look at the
benzodi ze ines. “E” is incorrect. Li id e ulsion re ers to the monitor. You obtain an ECG which shows the ollowing: (Fig. 1-1).
liquid tty cids given s rt o tot l renter l nutrition nd
theoretic lly c n be used to bind t-soluble drugs in the blood. Question 1.2.3 What is the patient’s rhythm?
C se series su ort consider tion o li id e ulsion or c lciu A) Mono or hic ventricul r t chyc rdi .
ch nnel blocker, bet -blocker, tricyclic ntide ress nt overdose, B) Sinus t chyc rdi with bundle br nch block.
nd other t-soluble drugs but only in c ses o re r ctory c rdi c C) P roxys l su r ventricul r t chyc rdi .
rrest or c rdiov scul r coll se— nd cert inly not be ore the D) ors des de ointes.
irw y h s been secured. E) T ird degree he rt block.

FIGURE 1-1. ECG or patient in question 1.2.3.


Answer 1.2.3 The correct answer is “D.” T is is tors des de cl ss Ib nti rrhyth ic, which y urther rolong the QRS nd
ointes (in French it liter lly e ns “twisting o the oints,” but worsen the c rdi c toxicity o the tricyclic. “D” is incorrect or
in every l ngu ge it e ns “ hysici n’s stress test”), which is two re sons. First, since os henytoin is et bolized to henyt-
subty e o oly or hic ventricul r t chyc rdi . ors des de oin, the concern bout e c cy lies. Second, os henytoin is
ointes c n be recognized by the v rying litude o the co - rodrug nd requires dequ te circul tion nd ren l nd he tic
lex in so ewh t regul r ttern. “A” is incorrect bec use the unction to be converted into ctive drug. I our tient beco es
co lexes re not ono or hic. “B” is incorrect or two re - hy otensive with oor liver nd ren l er usion, dequ te drug
sons. First, there re no P w ves visible. Second, sinus t chyc r- levels ight not be chieved. Fin lly, both henytoin nd os-
di should not h ve v ried litude. “C” is incorrect bec use, henytoin c n c use hy otension—not wh t you need in this
g in, there re no P w ves nd the co lexes re oly or hic. unst ble tient.
“E” is incorrect bec use there re no P w ves.
You correct the arrhythmia and stop the seizures, and she is
Question 1.2.4 This patient needs treatment post haste. admitted to the intensive care unit.
A ter taking care o the ABCs, what is the ONE BEST drug
or the treatment o this arrhythmia in a patient with a tri HELPFUL TIP:
cyclic overdose? A patient who is entirely asymptomatic 6 hours a ter a
A) Es olol. tricyclic overdose is unlikely to have any serious con-
B) Lidoc ine. sequences rom the ingestion. They can be “medically
C) Sodiu bic rbon te. cleared” at that point or admission to psychiatric unit.
D) Proc in ide. Note that “symptomatic” may just be tachycardia or
E) A iod rone. mild con usion. We mean the entirely asymptomatic
Answer 1.2.4 The correct answer is “C.” T e tre t ent o
choice or rrhyth i s in tients with tricyclic overdose is
sodiu bic rbon te. R ising the H nd d inistering sodiu Objectives: Did you learn to . . .
see to “ ri e” the sodiu ch nnels in the he rt, reversing • Understand the importance o the A–B–Cs in an unstable
the toxicity o the tricyclic. Proc in ide (“D”) nd quinidine patient?
should not be used bec use they ct in si il r shion to tricy- • Describe the role o umazenil in toxicologic emergencies?
clics nd y worsen the roble . Lidoc ine (“B”) c n be used • Manage a tricyclic overdose?
s c n iod rone (“E”), but they re not the best choices. Bet - • Recognize ECG ndings in a tricyclic overdose?
blockers such s es olol (“A”) c n worsen hy otension nd • Recognize torsades de pointes and its treatment in the
should be voided. context o a tricyclic overdose?

T is is not your patient’s lucky day. She begins to seize a er

the administration o the bicarbonate. QUICK QUIZ: DESIGNER AND CLUB DRUGS

Question 1.2.5 The treatment o choice or this seizing An 18-ye r-old le resents er rty. He is h ving ltern t-
patient is: ing e isodes o co b tive beh vior inters ersed with e isodes o
A) Lor ze . co . He beco es l ost neic during the e isodes o co .
B) Re e t the bolus o sodiu bic rbon te nd st rt bic r- He h s ltern ting br dyc rdi (while in co ) nd t chyc rdi
bon te dri . when w ke. T e tient is lso h ving yoclonic seizures. His
C) Phenytoin (Dil ntin). seru lcohol level is zero, nd his u ils re iotic.
D) Fos henytoin (Cerebryx).
E) None o the bove. T e ost likely drug c using this is:
A) Ecst sy (MDMA).
Answer 1.2.5 The correct answer is “A.” Benzodi ze ines re B) GHB (g -hydroxybutyr te k “liquid ecst sy”).
the tre t ents o choice in tricyclic-induced seizures. While C) Meth het ine.
ost seizures re sel -li ited, it is i ort nt to control sei- D) LSD (lysergic cid diethyl ine k “ cid”).
zures bec use the result nt cidosis c n worsen tricyclic tox- E) O i te overdose.
icity (beyond the ct th t rolonged seizures c n c use CNS
injury). “B” is incorrect. T is tient is lre dy lk linized, nd The correct answer is “B.” T e e isodic co nd br dy-
lthough sodiu bic rbon te is the re erred ther y or tricy- c rdi inters ersed with e isodes o extre e git tion re
clic-induced c rdiov scul r toxicity, sodiu bic rbon te is not l ost thogno onic o GHB overdose. GHB intoxic tion
rticul rly e ective in tricyclic-induced seizures. “C,” henyt- lso c uses in oint u ils. “A” is incorrect bec use MDMA
oin, c n be used, but benzodi ze ines nd henob rbit l should c uses n het ine-like re ction with git tion, hy er-
be d inistered rst i ossible. In ddition to not working well tension, hy erther i , t chyc rdi , etc. “C” is incorrect or
s n ntie ile tic drug in tricyclic overdose, henytoin is lso the s e re son. “D” is incorrect bec use LSD r rely (i ever)


Drug Class Examples Signs and Symptoms
Anticholinergic Tricyclics, diphenhydramine, scopolamine, Tachycardia, ushing, dilated pupils, low-grade temperature, and
loco weed (jimson weed), some con usion. Mnemonic: Dry as a bone, red as a beet, mad as a hatter, blind
mushrooms, etc. as a bat

Opiates Morphine, heroin, codeine, oxycodone, etc. Pinpoint pupils, hypotension, hypopnea, coma, hypothermia

Cholinergic Organophosphate or carbamate Lacrimation, salivation, muscle weakness, diarrhea, vomiting, miosis.
pesticides, some mushrooms Mnemonic: SLUDGE BBB (salivation, lacrimation, urination, diarrhea, GI
upset, emesis . . . Bradycardia, bronchorrhea, bronchospasm)

Sympathomimetic Cocaine, ecstasy, methamphetamine Tachycardia, hypertension, elevated temperature, dilated pupils (mydriasis)

Gamma-hydroxybutyrate GHB, liquid ecstasy, etc. Alternating coma with agitation, hypopnea while comatose, bradycardia
(GHB) while comatose, and myoclonus

c uses co . “E” is incorrect bec use tients with o i te Question 1.3.1 Which o the ollowing IS NOT a criterion or
overdoses re gener lly so nolent or co tose without in- clearing the cervical spine clinically?
ters ersed e isodes o git tion, lthough o i te use may lso A) Absence o ll neck in.
c uses iosis (be w re th t not ll n rcotic overdoses re s- B) Nor l ent l st tus including no drugs or lcohol.
soci ted with in oint u ils). GHB is odorless nd h s slight C) Absence o distr cting injury (such s n nkle r cture).
s lty t ste. It h s beco e drug o choice or “d te r e.” T e D) Absence o r lysis or nother “h rd” sign th t could be
toxicity tends to be sel -li ited nd c n be tre ted with intu- c used by neck injury
b tion i needed long with tincture o ti e. T e h l -li e is E) Absence o retrogr de nesi .
only 27 inutes.
Answer 1.3.1 The correct answer is “A.” P tients c n h ve l t-
er l neck in nd still h ve their cervic l s ines cle red clini-
QUICK QUIZ: TOXIDROMES c lly. However, no one will ult you or obt ining r diogr hs
in tients with l ter l uscul r (e.g., tr ezius) neck in.
A tient resents to the hos it l with di henhydr ine P tients with centr l neck in (e.g., over the s inous rocesses)
overdose. DO need i ging (r diogr hs ± C ) to cle r their cervic l
s ine. All o the other criteri re required in order to clinic lly
Which o the ollowing signs nd sy to s re you likely to cle r the cervic l s ine ( ble 1-2). T ese criteri h ve been
nd in this tient? v lid ted in both dult nd edi tric tients.
A) Br dyc rdi , dil ted u ils, ushing, nd incre sed bowel
B) Br dyc rdi , in oint u ils, ushing, nd decre sed bowel HELPFUL TIP:
sounds. The most common cause o missed ractures is an in-
C) chyc rdi , dil ted u ils, di horesis, nd incre sed adequate series o radiographs. An adequate series o
bowel sounds. radiographs or the cervical spine includes an AP ilm,
D) chyc rdi , dil ted u ils, ushing, nd decre sed bowel a lateral ilm including the top o T-1, and an odontoid
sounds. ilm. CT should be done i radiographs are negative
E) chyc rdi , in oint u ils, ushing, nd incre sed bowel and there is still clinical suspicion o a racture. Flexion–
sounds. extension views add little and should be avoided.

The correct answer is “D.” T is tient h s n nticholiner-

gic toxidro e. oxidro es re sy to co lexes ssoci-
ted with rticul r overdose th t should be i edi tely
recognized by the clinici n. Co on toxidro es re listed
in ble 1-1. No central neck pain on questioning or palpation

No distracting, pain ul injury (e.g., bone racture)

CASE 1.3
No symptoms or signs re erable to the neck (paralysis, stinger-type
A patient presents to your o ce with neck pain a er a motor injury, etc.)
vehicle accident. He was restrained and the airbag deployed.
He notes that he had some lateral neck pain at the scene. He Normal mental status including no drugs or alcohol. This includes any
retrograde amnesia, etc.
continues to have lateral neck pain.

T e patient’s daughter, aged 4 years, was in the same motor HELPFUL TIP:
vehicle accident and also had her cervical spine cleared by There is currently controversy regarding treatment o
radiograph. However, you get a call rom the ED 48 hours acute spinal cord injuries with IVmethylprednisolone 30
a er the initial accident that she is paralyzed rom just mg/kg bolus (3 g in an adult) ollowed by a 5.4 mg/kg
above the nipple line down (never a good thing—you drip or 24 hours. The e icacy o this therapy in spinal
quickly make a mental note to make sure your malpractice cord injury is limited (i it exists at all), and its e icacy in
insurance premiums are paid up). You review the initial SCIWORA is unknown. There are also secondary compli-
radiographs with the radiologist, which are negative as is cations rom the steroids including hyperglycemia, my-
a C o the cervical spine bones done a er the onset o the opathy, and in ections (e.g., pneumonia). We don’t use it.
Question 1.3.4 The ather is, understandably, irate that his child
Question 1.3.2 The most likely cause o this patient’s paral is now paralyzed. You can tell him that the natural history o
ysis is: SCIWORA syndrome in THIS CHILD is likely to be the ollowing:
A) Missed tr nsection o the thor cic cord. A) Continued r lysis with the necessity o long-ter , er -
B) Conversion re ction ro the sychologic l tr u o the nent d t tion to the injury.
ccident. B) Progression o the injury over the next week to include ur-
C) Sub r chnoid he orrh ge. ther r lysis in n scending shion.
D) SCIWORA syndro e. C) Resolution o r lysis nd sensory sy to s over the next
E) Guill in–B rre syndro e. sever l onths.
D) Resolution o ll sy to s exce t sensory sy to s o the
Answer 1.3.2 The correct answer is “D.” T is likely re resents next sever l onths.
SCIWORA syndro e (s in l cord injury without r diologic E) L rge l wsuit yout on the w y. Do not ss go; do not col-
abnor lity). T is occurs ro stretching o the cord second- lect $200; go directly to l r ctice ttorney.
ry to exion/extension-ty e ove ent in n ccident. P tients
with SCIWORA syndro e y be r lyzed t the ti e o ini- Answer 1.3.4 The correct answer is “C.” Gener lly, tients
ti l resent tion (in the event o cord tr nsection) or y h ve with SCIWORA syndro e reg in their strength nd sensory
del yed resent tion u to 72 hours er the injury. “A” is incor- bilities over ti e. However, this depends on when they pres-
rect bec use cord tr nsection would resent with r lysis ent with symptoms! P tients who resent with r lysis right
i edi tely t the ti e o injury. “B” is incorrect bec use this er the ccident y h ve co lete cord tr nsection nd
child is 4 ye rs old, nd conversion re ction is unlikely in chil- thus will not reg in unction. For this re son, it is i ort nt to
dren. In ddition, conversion re ction IS ALWAYS di gnosis obt in n MRI on ll tients with SCIWORA syndro e ( nd
o exclusion. “C” nd “E” re incorrect bec use this is neither ny tr u -induced r lysis or th t tter).
the resent tion o sub r chnoid he orrh ge (he d che, sti
neck, erh s oc l neurologic sy to s) nor o Guill in– Objectives: Did you learn to . . .
• Clinically “clear” the cervical spine and decide when to order
B rre syndro e ( rogressive nu bness nd we kness ro
cervical spine radiographs?
utoi une yelitis).
• Understand the physiology, natural history, and management
o SCIWORA syndrome?
Question 1.3.3 The next step in the management o this
patient is:
A) Avoid hy otension nd hy oxi to revent second ry insult CASE 1.4
to the cord A patient with an extensive history o alcohol use presents to
B) Fluid restriction nd diuretics to reduce cord ede . the ED a er drinking a bottle o automobile winter gas treat-
C) M nnitol to reduce cord ede . ment (Rothschild Vintage, 1954). He is intoxicated, has a
D) Neurosurgic l intervention to deco ress the cord. headache, and describes a “misty” vision, “like a snowstorm”
E) Lolli o nd gi c rd or “service recovery.” (i you live in southern Florida or Cali ornia, call one o us
in Iowa or a description). He is tachycardic and tachypneic.
Answer 1.3.3 The correct answer is “A.” P tients with cord You start an IV and administer saline. You obtain a blood
injury should be onitored closely to void hy otension nd gas, which shows a mild metabolic acidosis.
hy oxi , both o which will urther d ge the lre dy co ro-
ised s in l cord. Neither diuretics (“B”) nor nnitol (“C”) Question 1.4.1 A metabolic acidosis is consistent with all o
will be use ul in this situ tion. “D” is incorrect bec use the ro- the ollowing ingestions EXCEPT:
cess o SCIWORA involves stretching o the cord ( nd subse- A) Ethylene glycol.
quent dys unction) r ther th n cord co ression such s would B) Meth nol.
be seen with bony injury. “E” ight be the right choice i you C) Eth nol (e.g., vodk , gin).
re t king this test s “ tient ex erience ex ert” inste d o D) Petroleu distill tes (e.g., non- lcohol cont ining g soline
doctor; but doctors should choose “A.” roducts).

Answer 1.4.1 The correct answer is “D.” Ethylene glycol, eth- TABLE 1-3 CAUSES OF ACIDOSIS
nol, nd eth nol c n ll c use et bolic cidosis. Hydroc r-
Causes o an Lactic acidosis
bons (e.g., g soline roducts) do not c use et bolic cidosis.
elevated anion gap Diabetic ketoacidosis
T e in ni est tion o hydroc rbon toxicity is second ry to acidosis Ingestions such as ethanol, methanol, etc.
the inh l tion nd s ir tion o the hydroc rbon nd the result-
ing neu onitis.
Alcoholic ketoacidosis

T is patient’s electrolytes are as ollows: sodium 135 mEq/L, Causes o a normal GI bicarbonate loss (e.g., chronic diarrhea)
bicarbonate 12 mEq/L, chloride 108 mEq/L, BUN 12 mg/dL, anion gap acidosis Renal tubular acidosis (types I, II, and IV)
Cr. 1.0 mg/dL. Interstitial renal disease
Ureterosigmoid loop
Question 1.4.2 This patient’s anion gap is: Acetazolamide and other ingestions
A) 13. Small bowel drainage
B) 15.
C) 23.
D) Un ble to c lcul te the nion g with the in or tion A) Hy o ne .
rovided. B) O tic disk bnor lities.
C) Abdo in l in nd vo iting.
Answer 1.4.2 The correct answer is “B.” By convention, the D) B s l g ngli he orrh ge.
nion g is c lcul ted without using jor c tion, ot ssiu . E) Meninge l signs, such s nuch l rigidity.
T us, the nion g is c lcul ted s ollows:
Answer 1.4.4 The correct answer is “A.” Hy o ne is not
sodiu − (chloride + bic rbon te). co only seen in eth nol oisoning until the tient is close
to de th. In ct, the reverse is true. chy ne is requent
In this tient, the nion g = 135 − (108 + 12) = 15. nding in eth nol overdose. T is kes sense. T e tient
is trying to co ens te or et bolic cidosis by blowing o
T e nor l nion g is ty ic lly considered to be 12 or less. CO2. O tic disk bnor lities, bdo in l in nd vo iting,
However, since lbu in is the jor un e sured nion in the b s l g ngli he orrh ge, nd eninge l signs re ll seen s
seru , the nion g should be djusted or hy o lbu in- rt o eth nol toxicity. It is thought th t ny o these signs
e i . Every 1 g decre se in lbu in will incre se the nion nd sy to s re second ry to centr l nervous syste (CNS)
g by bout 3. T ere ore, you should subtr ct (3 × [nor l he orrh ge.
lbu in- ctu l lbu in]) to get the “re l” nion g . T e
nor l lbu in is considered to be 4. So, let us s y we c l- You can test or ethanol at your hospital but do not have a
cul te n nion g o 16 but the lbu in is 2. In this c se test or methanol on a stat basis and want to be sure that this
the corrected nion g will be (16 − [3 × (4 − 2)] = 16 − 6), patient is not just saying he has a methanol ingestion in order
or 10. to obtain alcohol (a treatment or methanol ingestion—break
out the single malt scotch!).

HELPFUL TIP: Question 1.4.5 What test is most likely to help you deter
In methanol ingestions, the severity o acid–base distur- mine i the patient has methanol ingestion?
bance is generally a better predictor o outcome than A) Co lete blood cell count (CBC).
serum methanol levels. B) BUN/cre tinine.
C) Liver enzy es.
D) Seru os ol lity.
Question 1.4.3 All o the ollowing are causes o an anion E) A yl se nd li se.
gap acidosis EXCEPT:
A) L ctic cidosis. Answer 1.4.5 The correct answer is “D.” With e sured
B) Di betic keto cidosis. seru os ol lity, you c n c lcul te the os ol r g . o do
C) Ren l tubul r cidosis. so, subtr ct the tot l measured seru os oles ro the
D) Ure i . os oles known to be due to eth nol (e ch 100 g/dL o eth -
E) Ingestions such s eth nol. nol ccounts or roxi tely 22 os oles). I there is n ele-
v ted os ol r g , it is evidence o circul ting, un e sured
Answer 1.4.3 The correct answer is “C.” See ble 1-3 or ore os ole. A nor l os ole g is so ewhere between −10 nd
on c uses o nion g cidosis. 20 Os /kg.
In this c se, or ex le:
Question 1.4.4 Which o the ollowing ndings IS NOT
requently seen in patients with methanol ingestion? Me sured seru os ol lity = 368.

Blood lcohol = 200 g/dL or bout 44 os oles. A) C lciu chloride.

B) Gluc gon.
C lcul ted os ol lity = 2(N ) + BUN/2.8 + glucose/18 = C) Milrinone.
280 + 6 + 8 = 294. D) High-dose insulin.
E) All o the bove.
So, os ol r g = 368 − (294 + 44) = 30.
The correct answer is “E.” In bet -blocker overdoses, the ol-
T is e ns th t there re 30 un e sured os oles th t could, in lowing ndings y be observed: br dyc rdi , AV block, hy o-
the clinic l context o the c se, re resent eth nol. T us, we know tension, bronchos s , n use , e esis, nd hypoglycemia. T is
th t the tient did not si ly overindulge on eth nol ( eth nol, is very si il r to the resent tion o c lciu ch nnel blocker
such s “g s dry,” will ke one intensely drunk . . . but h s obvi- overdose, but c lciu ch nnel blocker overdose o en l cks
ous downsides). bronchos s nd tients re hyperglycemic s insulin rele se
ro the islet cells is c lciu de endent. When bet -blocker
You decide that there is su cient evidence that this patient overdose h s been identi ed, the usu l tre t ents re e loyed
has ingested methanol to institute treatment. (e.g., IV uids, v so ressors, irw y rotection, ch rco l). I
convention l v so ressors h ve iled, gluc gon in dose o 3
Question 1.4.6 Appropriate treatment(s) or this patient to 5 g IV bolus nd dri t 1 to 5 g/hr y be e ective
include: in tre ting bet -blocker overdose. It is gener lly re erred over
A) Fo e izole (4-MP). tro ine in this situ tion. Milrinone nd other hos hodiester-
B) Acetyls licylic cid. se inhibitors y lso be used but re considered third-line
C) Eth nol. gent. Like-wise, c lciu is considered third-line gent in
D) A nd C. bet -blocker overdose. C lciu chloride y otenti te the c-
E) All o the bove. tion o gluc gon. T ere is lso growing body o liter ture su -
orting use o high dose insulin-euglycemia or bet -blocker,
Answer 1.4.6 The correct answer is “D.” Both Fo e izole c lciu ch nnel blocker, or co bin tion overdoses. T e insulin
(4-MP) nd eth nol re used or eth nol ingestion. T e ide is st rted t 0.5 units/kg/hr nd titr ted to s high s 10 units/
is to slow down the et bolis o the eth nol. T e toxicity kg/hr, titr ted by he odyn ic i rove ent (see Clin Toxicol
o eth nol is c used by or ic cid, which is by- roduct (Phila). 2011;49(4):277–283, or ex le). Does it see coun-
o eth nol et bolis . Eth nol is et bolized by lcohol terintuitive to give gluc gon nd insulin? Both e r to iti-
dehydrogen se, the s e enzy e th t bre ks down eth nol. g te the deleterious e ects o bet -blockers on c rdi c yocyte
T us, eth nol et bolis is co etitively inhibited by eth - et bolis , lthough the ech nis is not co letely under-
nol. T e s e holds true or o e izole, which is co etitive stood. Both c n be given (usu lly in sequence with the gluc gon
inhibitor o lcohol dehydrogen se. Fo e izole nd eth nol rst) to the s e tient or bet -blocker overdose. Remember
c n both be used or ethylene glycol ingestion s well. “B” is to maintain euglycemia i using insulin or beta-blocker or
incorrect. Acetyls licylic cid (ASA), or s irin, h s no role in calcium channel blocker overdose.
eth nol ingestion, nd would likely worsen ny g stritis or
he orrh ging.

HELPFUL TIP: Which o the ollowing c n be used to incre se the et bolis

Hemodialysis should be available or any patient who o lcohol in n intoxic ted tient?
has ingested methanol. Indications or hemodialysis in- A) IV uids.
clude methanol level >50 mg/dL, severe and resistant B) Ch rco l.
acidosis, and renal ailure. C) Forced diuresis.
D) GABA nt gonists such s u zenil.
Objectives: Did you learn to . . . E) None o the bove.
• Recognize mani estations o alcohol ingestion?
• Identi y causes o metabolic acidosis with elevated and The correct answer is “E.” Drunk tients, no tter how
normal anion gaps? uch they nnoy you, will just h ve to slee it o . T e r te o
• Use the osmolar gap to narrow down the dif erential diagno- lcohol et bolis is xed with zero-order kinetics t lower
sis o metabolic acidosis? doses ( xed et bolic r te) nd rst-order kinetics t higher
doses (r te ro ortion l to levels). In gener l, this r te is in
the r nge o 9 to 36 g/dL/hr with 20 g/dL/hr being the
QUICK QUIZ: BETA-BLOCKER OVERDOSE cce ted nor . At this oint, there re no v il ble gents to
incre se the et bolis o eth nol. “B” is incorrect bec use
Which o the ollowing h s been shown to be use ul in bet -blocker eth nol is too r idly bsorbed or ch rco l to be o ny ben-
overdose when convention l, drenergic ressors re ine ective? e t.

c rboxyhe oglobin level in these tients. I the tre t ent deci-

QUICK QUIZ: TOXICOLOGY 2 sion is de b sed on the c rboxyhe oglobin level, the level
rojected to ti e zero gives the ost ccur te in or tion bout
T e best ther y or seizures second ry to isoni zid ingestion is: the degree o ex osure. T e rest o the nswers re incorrect.
A) Lor ze .
B) Phenytoin. T e ather has a headache and a time zero carboxyhemoglo-
C) Pyridoxine. bin level o 12%. T e mother, who is pregnant, is asymptom-
D) T i ine. atic and has a time zero carboxyhemoglobin level o 18%.
E) Phenob rbit l. Both o the children are asymptomatic. T e 6-year-old has
a time zero carboxyhemoglobin o level o 18% while the
The correct answer is “C.” Isoni zid is vit in B6 nt gonist. 8-year-old has a level o 23%.
T us, yridoxine (in ssive doses!) is the drug o choice in
isoni zid-induced seizures. T ese seizures re o en resist nt to Question 1.5.3 The rst step in the treatment o these
convention l ther y. Look or this ty e o overdose in tients patients is:
who re being tre ted or tuberculosis (either ctive or l tent A) St rt n IV nd d inister s line.
dise se). B) St rt N- cetylcysteine, which is ree r dic l sc venger.
C) St rt continuous ositive irw y ressure (CPAP) to xi-
CASE 1.5 ize ir ow by kee ing the irw ys ro coll sing.
D) Ad inister 100% oxygen.
A amily o our comes into your ED a er being exposed to E) Intub te the ost severe tient, 100% oxygen or the others.
carbon monoxide (CO). T ey were in an idling car and were
running the engine and heater to stay warm. You want to get Answer 1.5.3 The correct answer is “D.” Bec use CO co eti-
a carboxyhemoglobin level on the whole amily but cannot tively binds to he oglobin in l ce o oxygen nd in ct h s
get an arterial blood gas rom the youngest child. gre ter nity or he oglobin th n oxygen, high- ow 100%
oxygen is the cornerstone o tre ting CO oisoning. T e h l -
Question 1.5.1 What is your response? li e o CO in tient bre thing roo ir is roxi tely 300
A) Check ulse oxi etry, nd i the oxygen s tur tion is nor l, inutes; this is reduced to 90 inutes when bre thing high ow
be re ssured. oxygen nd reduced to 30 inutes when bre thing 100% hy er-
B) Check end-tid l c rbon dioxide. b ric oxygen. T us, the rst step in CO poisoning is to administer
C) Check venous c rboxyhe oglobin level. 100% oxygen. T e rest o the nswers re incorrect. I the tient
D) Check venous c rboxyhe oglobin nd correct or the di - is not ventil ting well nd requires intub tion, this would be
erence between venous nd rteri l s les. ro ri te, nd the FiO2 should be set to 100%, reg rdless o
the tient’s ulse oxi etry or rteri l oxygen re dings. How-
Answer 1.5.1 The correct answer is “C.” A venous c rboxyhe- ever, in our tients who re bre thing without di culty, there
oglobin is just s ccur te s n rteri l c rboxyhe oglobin— will be no dv nt ge ( nd uch higher risk) to intub tion.
in ct, no correction is needed, which is why “D” is wrong— nd
it is uch less in ul to dr w. “A” is incorrect bec use the ulse Question 1.5.4 Which o the ollowing can be seen with
oxi eter does not re ect hy oxi in c rbon onoxide oison- carbon monoxide poisoning?
ing. T us, st nd rd ulse oxi etry is useless in deter ining A) Rh bdo yolysis.
the c rboxyhe oglobin level. “B” is incorrect bec use end-tid l B) C rdi c ische i .
c rbon dioxide is e suring CO2 nd not CO. C) Long-ter neurologic sequel e, including de enti .
D) Pul on ry ede .
Question 1.5.2 When determining which patients need E) All o the bove.
hyperbaric oxygen on the basis o a carboxyhemoglobin
level, the level to rely upon is: Answer 1.5.4 The correct answer is “E.” All o the bove c n
A) T e c rboxyhe oglobin level on rriv l to the ED. be seen with c rbon onoxide oisoning. Addition l ndings
B) T e c rboxyhe oglobin level t 4 hours er ex osure. include l ctic cidosis, seizures, synco e, nd he d che. “C”
C) T e c rboxyhe oglobin level rojected to “ti e zero” (e.g., deserves bit ore discussion. Long-ter neurologic sequel e
t the ti e o ex osure). c n develo ro d ys to onths er the ex osure nd include
D) None o the bove. cognitive de cits, oc l neurologic de cits, ove ent disor-
ders, nd erson lity ch nges. It e rs th t using hy erb ric
Answer 1.5.2 The correct answer is “C.” A jor consider- oxygen in the ro ri te tient c n reduce long-ter neuro-
tion reg rding the initi tion o hy erb ric oxygen ther y is logic sequel e.
the tient’s clinic l situ tion. More severely ill tients with
CO oisoning (e.g., severe cidosis, unconscious, unres onsive) Your closest diving chamber is about 90 minutes away and
should be considered c ndid tes or hy erb ric oxygen, nd will hold only one patient at a time. You need to make a deci-
so e hy erb ric oxygen centers will tre t reg rdless o e sured sion about who to send or hyperbaric oxygen.

Question 1.5.5 Which patient will bene t most rom hyper C) A co on org nis in in ected dog bites is Staphylococcus
baric oxygen therapy? aureus.
A) Asy to tic regn nt other, ti e zero c rboxyhe o- D) Pri ry closure o dog bite wounds is n cce t ble o tion
globin o 18%. (exce t erh s on the h nds nd eet).
B) Asy to tic 6-ye r-old, ti e zero c rboxyhe oglobin o E) T ey lw ys require ntibiotics.
C) Asy to tic 8-ye r-old, ti e zero c rboxyhe oglobin o Answer 1.6.1 The correct answer is “E.” All o the rest re
23%. true st te ents. Dog bites (exce t, erh s, or those ro
D) Adult le with ild he d che only, ti e zero c rboxyhe- te cu oodles n ed Fi ) tend to be crush injuries ( s con-
oglobin level o 12%. tr sted with c t bites, which re ri rily uncture wounds).
T e in ection r te is bout the s e s other l cer tions. Bites
Answer 1.5.5 The correct answer is “A.” Gener lly cce ted on the h nds nd eet tend to h ve higher r te o in ection.
criteri or hy erb ric oxygen include: ent l st tus ch nges, Most dog bite in ections re oly icrobi l with ixed erobic
sy to tic c rboxyhe oglobin levels >25%, cidosis, c rdio- nd n erobic b cteri . S. aureus is o en resent, long with
v scul r dise se, nd ge >60. Obviously, these re rel tive criteri . other org nis s including Pasteurella nd Capnocytophaga (s y
An otherwise nor l 61-ye r-old with ild ex osure need not th t one ten ti es st). Other org nis s include Streptococcal
h ve HBO. Pregnancy is an indication or HBO therapy bec use s ecies nd Gr -neg tive s ecies. Dog bites do not gener lly
et l he oglobin h s high nity or c rbon onoxide, with require ntibiotic ro hyl xis, exce t under cert in circu -
the etus cting s “sink” or CO. T e high erobic et bolic st nces (e.g., resent >9 hours er bite, i unoco ro ised,
ctivity o et l develo ent is i cted gre tly by ex osure to l rge, or co lic ted wound).
the n erobic environ ent cre ted by c rbon onoxide.
Question 1.6.2 You are concerned about rabies prophylaxis.
Question 1.5.6 All o the ollowing are well established Which o the ollowing is the best next step?
consequences o hyperbaric oxygen EXCEPT? A) Isol te the sus ect ni l or 3 d ys.
A) Seizures. B) S cri ce the sus ect ni l nd ex ine the liver.
B) Psychosis. C) Ad inister r bies i une globulin IM.
C) Myo i . D) Ad inister r bies i une globulin IV ollowed by r bies
D) E r nd ul on ry b rotr u s. v ccin tion series.
E) Direct ul on ry oxygen toxicity. E) Ad inister r bies i une globulin by in ltr ting it round
the wound ollowed by r bies v ccin tion series.
Answer 1.5.6 The correct answer is “B.” All o the rest re
ound s result o hy erb ric oxygen. “C,” yo i , is ctu lly Answer 1.6.2 The correct answer is “E.” You should in ltr te
ound in u to 20% o tients being tre ted with hy erb ric r bies i une globulin round the wound nd then begin the
oxygen. It is due to direct toxicity o oxygen on the lens nd usu- r bies v ccin tion series. In ltr te s uch o the i une glob-
lly recovers within weeks to onths. ulin s ossible round the wound nd d inister the re inder
Objectives: Did you learn to . . . IM t di erent site. Do not give more than the recommended
• Diagnose and manage patients with carbon monoxide dose o immunoglobulin. T is can reduce the immunogenic-
poisoning? ity o the vaccine. “A” is incorrect bec use ni ls need to be
• Describe complications o carbon monoxide poisoning? isol ted or 10 days, not 3. “B” is incorrect. I c tured, the ni-
• Identi y patients who may bene t rom hyperbaric oxygen l c n be s cri ced but the br in should be ex ined—not
therapy? the liver. “C” nd “D” re both incorrect ethods o d inis-
• Describe the complications o hyperbaric oxygen therapy? tering the v ccine nd i une globulin. Note th t the ver ge
incub tion eriod o r bies is 85 d ys. So, i unizing u to
3 onths (90 d ys) er the bite-event is indic ted.
CASE 1.6
A 50-year-old man comes to your ED a er being bitten by a Question 1.6.3 Which o the ollowing requires rabies pro
stray dog outside your hospital. Apparently, there is a prob- phylaxis in all cases?
lem with roving packs o eral dogs in your part o town. T e A) Str y r bbit bites.
bite was unprovoked and is on the abdomen. T e patient has B) Str y r t bites.
no other health history o note and has not taken antibiotics C) Str y b t bites.
or over a year. T ere is a 3-cm laceration on the abdomen. D) Str y squirrel bites.
E) Str y sn ke bites.
Question 1.6.1 All o the ollowing are true about dog bites
EXCEPT: Answer 1.6.3 The correct answer is “C.” All b ts should be
A) T ey tend to be ri rily crush-ty e injuries. considered r bid unless v il ble or observ tion nd testing.
B) In gener l, the in ection r te is si il r to l cer tion ro ny See ble 1-4 or det iled reco end tions. Also, see the CDC
other ech nis (e.g., kni e cut), exce t on the h nds nd eet. website or in or tion bout r tes o in ection in wild ni ls

TABLE 1-4 GUIDELINES FOR RABIES PROPHYLAXIS solutions, etc.) c n be used but re ore ex ensive nd do not
o er ny bene t in reduction in in ection r tes. “D” nd “E” re
General Rule Animals
both incorrect. As with ovidone-iodine, lcohol y be used
Always assume rabid unless Foxes, bats, raccoons, skunks, dogs, or cle ning skin but should be ke t out o the wound. It is toxic
available or testing cats, errets, other carnivores to tissue nd cts x tive. Hydrogen eroxide is lso toxic to
Judge on an individual basis Rodents (rats, mice, etc.), tissue nd should not be used in o en wounds—no tter wh t
lagomorphs (rabbits, etc.), squirrels gr nd s ys!
Never require rabies Nonmammals (snakes, lizards, etc.)
Question 1.6.5 How long a ter a laceration occurs can the
wound be closed primarily?
A) 6 hours.
B) 12 hours.
in your re . O note, nd true, there re r bid squirrels in Iow C) 18 hours.
City, our illustrious ho e: Google it. D) 24 hours.
E) Any o the bove c n be correct de ending on the wound.
Patients should receive a tetanus booster every Answer 1.6.5 The correct answer is “E.” T ere is no rbitr ry
10 years. For a contaminated wound, the tetanus boost- ti e li it to when wound c n be closed. F ci l wounds y
er should be within the last 5 years. Patients should re- be closed u to 24 hours er injury or cos etic re sons, while
ceive at least one dose o Tdap (tetanus, diphtheria, and you y not w nt to close other, cont in ted wounds ore
acellular pertussis) between ages 11 and 18 and a single th n 12 hours er injury. So e wounds you y not w nt
dose between ages 18 and 64. In addition, health-care to close t ll (e.g., bites to the h nd, wounds cont in ted
workers and those > 65 years o age who will be around with gre se, wounds cont in ted with nure, hu n bite
in ants should receive a single dose o Tdap. wounds), r ther llowing the to close by second ry intention.
Objectives: Did you learn to . . .
• Describe the indications or rabies prophylaxis?
• Recognize the issues that arise with animal bites and indica-
I a patient at risk or tetanus has not had a primary se-
tions or closure and/or prophylactic antibiotics?
ries o tetanus immunizations, administer tetanus im-
• List recommendations or tetanus prophylaxis?
mune globulin, and start the primary tetanus series.
• Use various wound irrigation solutions or cleansing
• Decide upon the time rame or wound closure?
You decide to irrigate this patient’s wound.

Question 1.6.4 Which o the ollowing statements is true

CASE 1.7
about irrigating a wound and subsequent risk o wound A 52-year-old male presents to your ED via ambulance
in ections? complaining o a headache a er a all. He was working and
A) Povidone-iodine s 50% irrig tion solution (e.g., Bet dine) ell approximately 10 . He notes no injury except or head
in the wound will decre se the in ection r te. and neck pain. A quick survey reveals that he has a BP o
B) Irrig tion with nor l s line is the only reco ended 128/86 mm Hg, pulse 100 bpm, and respirations o 12. T ere
ethod o cle ning wound. was no loss o consciousness at the scene. He “saw stars” and
C) Irrig tion with nor l s line nd irrig tion with t w ter was clumsy, dazed, and slow at the scene without any ocal
re equ lly e ective in reducing wound in ection r tes. neurologic de cit. He is now back to his baseline.
D) Use o e ine hrine with lidoc ine in wound incre ses the
r te o in ection. Question 1.7.1 A concussion is de ned as:
E) Irrig tion o wound with either lcohol or hydrogen er- A) Any neurologic sy to s (e.g., clu sy, d zed, or slow) er
oxide will reduce the r te o wound in ection. he d injury.
B) Loss o consciousness ollowed by return to b seline.
Answer 1.6.4 The correct answer is “C.” In ection r tes (in the C) Loss o consciousness with continued neurologic sy to s.
United St tes) re the s e whether the wound is irrig ted with D) Con usion er he d tr u reg rdless o whether the
nor l s line or t w ter. “A” is incorrect. Povidone-iodine is tient lost consciousness or not.
toxic to tissue nd oly or honucle r leukocytes nd ctu lly E) Any tr u tic injury to the he d.
y increase in ection r tes unless solution o 1% or less is
used. Full strength ovidone-iodine can be used on int ct skin Answer 1.7.1 The correct answer is “A.” A concussion is
s cle nser but should not be used in wound. “B” is incor- de ned s any neurologic sy to er he d tr u . Note
rect bec use other solutions ( olox er 188, b l nced s lt th t concussion does not require loss o consciousness. For

this re son, “B” nd “C” re incorrect. “D” is incorrect bec use D) T ere is u to 4% ch nce this tient will need neurosurgi-
ni est tions o concussion re not li ited to con usion but c l intervention.
lso include rotr cted vo iting, tr nsient nesi , slowed E) None o the bove.
ent tion, “dizziness,” nd other neurologic sy to s. “E” is
incorrect bec use by de nition, concussion requires neuro- Answer 1.7.3 The correct answer is “D.” In ro ri tely
logic sy to s. selected tients (e.g., those with signi c nt ech nis o
injury), bout 18% with GCS o 15 will h ve so e intr cr -
Your patient opens his eyes spontaneously, ollows com- ni l lesion, nd u to 4% will eventu lly require neurosurgic l
mands, answers all orientation questions correctly, but intervention. T ese re gener lly tients who h ve de ressed
appears unsteady when ambulating. skull r cture but nor l GCS. “A” is incorrect since nor l
GCS in nd o itsel does not llow one to orgo he d C in
Question 1.7.2 His Glasgow Coma Scale (GCS) is: tients with signi c nt ech nis o injury. “B” nd “C” re
A) 5. lso incorrect or the re sons noted e rlier. Re e ber th t the
B) 10. GCS is not line r; GCS o 14 is b d. P tients with GCS o 14
C) 14. must h ve C sc n—unless nother ctor in the clinic l deci-
D) 15. sion king dict tes otherwise (e.g., the nding is re-existing
E) 20. ro de enti or otherwise).

Answer 1.7.2 The correct answer is “D.” T e GCS is sc le Question 1.7.4 In an adult patient with a signi cant head
used to indic te the severity o neurologic dys unction nd is injury, which o the ollowing is NOT an indication or a
o en lied to victi s o he d tr u . Re e ber, however, head CT scan?
th t it does not redict ort lity or orbidity but is only used A) Intoxic tion with drugs or lcohol.
s descri tive sc le o the tient’s current st te. Only the x- B) Persistent vo iting.
i u score o 15 is considered nor l GCS. T ere re three C) A nesi or e ory de cit.
co onents to the GCS, listed in ble 1-5. D) Age gre ter th n 40.
E) Seizure.
Your chair and re rigerator each have a GCS o 3. Remember Answer 1.7.4 The correct answer is “D.” Older tients re t
that nothing can have a GCS less than 3. gre ter risk o develo ing serious intr cr ni l injuries, nd the
ge o 60 is usu lly considered n inde endent indic tion or
he d C with signi cant injury. While there is no “u er li it
Question 1.7.3 In patients with head injury, and indepen o nor l” or vo iting er he d tr u , the best d t v il-
dent o other actors, a GCS score o 15 indicates that: ble suggest th t ny vo iting er he d tr u in n adult
A) T e tient does not require he d C sc n. indic tes the need or he d C . T e currently reco ended
B) T ere is essenti lly no ossibility th t this tient h s n criteri or C o the he d in v rious ge grou s re listed in
intr cr ni l injury requiring surgic l intervention. ble 1-6.
C) T ere is little or no ossibility th t this tient h s ny oc l
intr cr ni l bleed. You obtain the head C and nd a subdural hematoma. You
arrange to trans er this patient or neurosurgical interven-
TABLE 1-5 GLASGOW COMA SCALE tion in order to drain the subdural hematoma. It is about a
Eye opening Spontaneous = 4
4-hour drive by ambulance to the nearest acility that has a
Mnemonic: “4 eyes” To speech = 3
To pain = 2
No response = 1
Question 1.7.5 Which o the ollowing is indicated as pro
phylaxis against increased intracranial pressure in this
Verbal response Alert and oriented = 5 patient?
Mnemonic: “Jackson 5” Disoriented conversation = 4 A) Hy erventil tion er intub tion.
Nonsensical speech = 3 B) IV nnitol.
Moaning = 2 C) rendelenburg osition.
No response = 1 D) IV dex eth sone.
Motor response Follows commands = 6
E) None o the bove.
Mnemonic: “Six Cylinders” Localizes pain = 5
Answer 1.7.5 The correct answer is “E.” None o the bove is
Withdraws rom pain = 4
indic ted s ro hyl xis or incre sed intr cr ni l ressure. “A”
Decorticate exion = 3
is incorrect or two re sons. First, this tient does not need to
Decerebrate extension = 2
be intub ted. Second, routine hy erventil tion s ro hyl xis
No response = 1
or incre sed intr cr ni l ressure is o no bene t. T is h s


Indications or Head CT A ter Trauma About two-thirds o patients with a mild head injury (not
Patient Age with a Signi cant Mechanism deemed severe enough to obtain a CT scan) will have
Adult • Intoxication some measurable decrement in unction at 1 month
• Age >60 secondary to post-concussion syndrome (J Emerg Med.
• Any memory de cit 2011;40:262).
• Vomiting (number o times unde ned)
• Seizure
• Headache

PECARN Rules for Pediatric Head Trauma and Need for CT Scan
Objectives: Did you learn to . . .
(The La ncet. 2009;374(9696):1160–1170.) • Use the GCS?
CT needed if: • Recognize which patients with head trauma are appropriate
Children >2 years • GCS <15 to obtain a head CT?
• Signs o a basilar skull racture • Manage patients presenting with potential intracranial injuries?
• Agitation, somnolence, slow responses, or
• Vomiting
• Loss o consciousness CASE 1.8
• Severe headache
• Severe mechanism (Fall >5 ft, MVC with A 23-year-old male is in a bar ght. He only had “two beers”
ejection, roll over, atality) and was just standing there “minding my own business” when
• Bike/pedestrian vs. car without helmet
he was jumped by those in amous “two dudes” (how can
• High Impact Object
• I there are changes during observation those two dudes be in so many places at once!). He presents
(MS change, worsening headache, new or to you about 1 hour a er the event with acial trauma. His
persistent vomiting) consider CT based on vitals are normal and he is mentating well (with the exception
clinical judgment. o some impaired judgment secondary to the alcohol). His
Children <2 years • GCS <15 blood alcohol level is 150 mg/dL, showing that he is legally
• Palpable skull racture intoxicated. On examination, you notice that the patient has
• Agitation, somnolence, slow responses, some epistaxis and a quite swollen nose. In addition, there is
perseveration one avulsed tooth and one tooth that is displaced.
• Scalp hematoma (except or rontal)
• LOC >5 seconds
• Severe mechanism ( all >3 ft, MVC with Question 1.8.1 The best way to transport an avulsed tooth
ejection, roll over, atality) is:
• Bike/pedestrian vs. car without helmet A) In sterile w ter.
• High impact object B) In the bucc l ucos er thorough w shing with so .
• I there are changes during observation
C) In gl ss o ilk.
(MS change, worsening headache, new or
persistent vomiting) consider CT based on D) Wr ed in s line-so ked g uze.
clinical judgment. I child <3 months o age E) Under illow.
consider parenteral pre erence and consider
scanning Answer 1.8.1 The correct answer is “C.” T e best w y to tr ns-
ort n vulsed tooth is (1) in gl ss o ilk, (2) in H nks’ b l-
nced s lt solution (good luck nding this when you need it!),
been well studied. Wh t h ens is th t hy erventil tion does or (3) in the bucc l ucos or under the tongue in tient in
c use v soconstriction reducing intr cr ni l blood ow nd who the risk o s ir tion is not concern. “A” is incorrect
there ore intr cr ni l ressure. However, hy erventil tion lso bec use sterile w ter is hy otonic nd yd ge the tooth
c uses ische i round the re o the injury nd y worsen root decre sing the success r te o re-i l nt tion. “B” is incor-
outco es. “B” is incorrect bec use ro hyl ctic nnitol, like rect bec use washing the tooth with soap is not ro ri te.
ro hyl ctic hy erventil tion, con ers no bene t. “C” is incor- Ag in, you w nt to int in the vi bility o the root i ossible.
rect. rendelenburg ositioning, or elev ting the legs bove the “D” is incorrect s well. I this is the only o tion v il ble to you,
he rt, would result in incre sed intr cr ni l ressure. T ere is it is better th n nothing, but gl ss o ilk or under the bucc l
very li ited d t to su ort or re ute ro hyl ctic elev tion o ucos is re erred. “E” is cce t ble only i you re tooth iry.
the he d o the bed to prevent incre sed intr cr ni l ressure;
while this will reduce intr cr ni l ressure, cerebr l er usion You call the dentist who is (o course) out o town. A dentist
ressure will lso be ildly reduced. For treatment o incre sed will not be available or at least 12 hours.
intr cr ni l ressure, there is slightly ore evidence or bene t
o elev ting the he d o the bed “D” is incorrect since steroids Question 1.8.2 Your best course o action at this point is:
re not use ul cutely in he d tr u . However, steroids re A) Continue to kee the tooth vi ble in gl ss o ilk.
use ul in cerebr l ede second ry to tu or. B) Continue to kee the tooth vi ble in the bucc l ucos .

C) Cle n the tooth nd kee it sterile nd dry or re-i l nt tion Answer 1.8.4 The correct answer is “B.” A se t l he to
in 12 hours re lizing th t bridge will rob bly be needed to is considered n e ergency. T e roble is th t the erichon-
hold the tooth in osition. driu , which su lies nutrition to the se tu , is no longer in
D) Reinsert the tooth into the socket yoursel . cont ct with the se tu bec use o the intervening he to .
T us, the se t l c rtil ge c n necrose le ding to er or ted
Answer 1.8.2 The correct answer is “D.” I there is going to se tu . Se t l he to s should be dr ined cutely nd the
be ny del y in rei l nt tion by dentist, the best course o nose cked to kee the erichondriu in cont ct with the
ction is to reinsert the tooth into the socket yoursel . “A,” “B,” se t l c rtil ge. “A” is incorrect (see revious question). “C”
nd “C” re ll incorrect bec use they will reduce the r te o suc- is incorrect. Kiesselb ch lexus is in the nterior nose nd is
cess ul rei l nt tion. venous lexus. Bleeding is e sily controlled nd gener lly is
sel -li ited. “D,” devi ted se tu , y indic te n underlying
HELPFUL TIP: r cture but in nd o itsel is not n e ergency.
Primary (“baby”) teeth should not be reinserted into
the socket! They ankylose to the bone preventing the You continue to evaluate this patient and note that he has the
eruption o the permanent tooth and cause a cosmetic loss o upward gaze in the right eye, the side on which he was
de ormity. hit. All o the other extraocular motions are intact.

Question 1.8.5 The most likely diagnosis in this patient is:

HELPFUL TIP: A) Blowout r cture with entr ent o the in erior rectus.
Any patient who is in the ED, says he only had three B) Blowout r cture with dys unction o the su erior rectus.
beers, and was “minding his own business” is probably C) Injury to cr ni l nerve III, which controls the su erior AND
not telling the truth on either account. in erior rectus uscles.
D) Volition l re us l to er or u w rd g ze on the right side
in this intoxic ted tient.
You now turn your attention to this patient’s bloody nose and
are trying to decide whether or not get an x-ray. Answer 1.8.5 The correct answer is “A.” T e ost likely di g-
nosis is blowout r cture with entr ent o the in erior rectus.
Question 1.8.3 The BEST timing or a radiograph o the T e orce o blow to the globe is tr ns itted to the in erior
nose is: orbit l w ll, which is the we kest oint in the orbit. T is c n
A) As soon s ossible er the tr u once other injuries re c use entr ent o the contents o the in erior orbit, includ-
st bilized nd ore i ort nt roble s re ddressed. ing the in erior rectus, c using n in bility to er or u w rd
B) As soon s ossible to ssure th t there re no bone r g- g ze. Due to disconjug te g ze, tients with entr ent o the
ents thre tening the br in. in erior rectus uscle ro blowout r cture y co l in o
C) T ere is no need or r diogr h cutely. You c n w it or 3 di lo i . “B” is incorrect bec use blowout r cture gener lly
or 4 d ys. re ers to the in erior orbit l w ll, which would not entr the
D) T ere is never ny indic tion or n s l r diogr hs. su erior rectus. In ddition, tients with n entr ed su e-
rior rectus would h ve di culty with downw rd g ze. “C” is
Answer 1.8.3 The correct answer is “C.” T ere is no need or incorrect bec use it is unlikely th t being hit in the ce would
r diogr hs cutely exce t in extr ordin ry circu st nces. T e c use n injury to CN III. In ddition, CN III lesion would
re sons or r diogr h re to docu ent r cture and to ssist in ect ll extr ocul r uscles exce t or the l ter l rectus (CN
reduction. Bec use o swelling, it is di cult to get good cos etic VI) nd the su erior oblique (CN IV). “D” is incorrect bec use
result reducing n s l r cture cutely. T us, r diogr h is indi- it is i ossible to ove the eyes inde endently o one nother
c ted in 3 to 4 d ys only i there is evidence o n s l de or ity once unless you re ch eleon or rticul rly t lented.
swelling h s resolved. I there is good cos esis nd the tient c n
bre the through his (they re l ost lw ys le) nose, r dio- HELPFUL TIP:
gr h is unnecess ry just to docu ent r cture. “A” nd “B” re Note that a blowout racture may be a good thing. Hav-
incorrect bec use, s noted e rlier, there is no re son to do r dio- ing the racture allows pressures to equilibrate and pre-
gr h t ll unless there is evidence o de or ity once the swelling vents orbital compartment syndrome (proptosis, visual
is resolved. “D” is incorrect or the re sons noted e rlier. loss, etc.). Proptosis with visual loss is a surgical emer-
gency mandating an immediate lateral canthotomy
Question 1.8.4 You get the epistaxis stopped and exam (easy to do . . . . check YouTube).
ine the nasal mucosa. Which one o these is considered an
A) Closed n s l r cture.
B) Se t l he to . T e patient has had a long night o partying, and it is 3:00
C) r u to Kiesselb ch lexus. AM Saturday morning when you call your consultant about
D) A devi ted se tu . the blowout racture. T e consultant is not happy and re uses

to see the patient acutely. He wants you to send him to the C) C ll the olice to re ove this tient ro your ED.
o ce in 3 days ( uesday morning). D) Use restr ints on the tient nd observe hi until sober, s
sed tive drugs y rolong ti e in the ED.
Question 1.8.6 Your response is: E) Let the tient le ve the ED with co etent dult.
A) o c ll nother consult nt; blowout r cture should be
ttended to i edi tely. Answer 1.8.7 The correct answer is “E.” T e tient w s ini-
B) Do nothing; ev lu tion in 2 to 3 d ys or blowout r cture, ti lly coo er tive nd co etent. Co etence is not b sed on
even with in erior rectus entr ent, is ro ri te. blood lcohol level but r ther on your judg ent o the tient’s
C) St rt steroids to reduce uscle ede to cilit te the s on- bility to ke r tion l decisions. We llow tients on n r-
t neous rele se o the entr ed uscle. cotics to ke decisions bout their own c re ll o the ti e
D) St rt ntibiotics nd hos it lize the tient so th t he c n be des ite h ving n rcotics on bo rd. T ere re tients who will
seen in the orning when the consult nt kes rounds. h ve c city nd re s e t blood lcohol o 200 g/dL nd
E) Stick ins in voodoo doll o your consult nt. others who y be i ired t 80 g/dL. So, judge c city
individu lly.
Answer 1.8.6 The correct answer is “B.” While blowout r c-
Objectives: Did you learn to . . .
tures with uscle entr ent require close ollow-u , there is • Treat acute dental trauma?
no need to intervene cutely. In ct, decision to o er te y
• Diagnose and manage nasal and periorbital trauma?
be del yed or u to 14 d ys. I the entr ent s ont neously
• Care or the intoxicated patient with minor trauma?
resolves when the swelling goes down (not unco on) nd
there is no di lo i or other co lic ting sy to s, surgery
is not needed. T e other nswers re ll incorrect bec use cute
intervention is not required in this tient. “E,” however, y be CASE 1.9
o so e bene t . . . de ending on your voodoo skills.
A 17-year-old emale ell asleep with her contact lenses in her
eyes last evening. T is morning she notes quite a bit o eye
HELPFUL TIP: pain and photophobia. You evert the eyelids (something that
Caveat to the above: In the pediatric population, im- should be done in all cases o possible oreign body) and nd
mediate surgical repair should be undertaken in trap- no evidence o a oreign body. When you stain her eye, you
door fractures. A trapdoor racture is one in which there nd a corneal ulcer.
is signi icant entrapment o the in erior rectus muscle. I
the muscle is le t entrapped in the pediatric population, Question 1.9.1 The treatment or this patient is:
restriction and ibrosis may occur, so immediate evalua- A) Debride ent with burr nd syste ic ntibiotics.
tion by a surgeon is warranted. Oral steroids at a dose o B) Debride ent with cotton sw b nd syste ic ntibiotics.
1 mg/kg may decrease edema in the irst 7 days limiting C) o ic l ntibiotics, cyclo legi , nd re err l to o hth l ol-
ultimate ibrosis. In patients with signi icant sinus dis- ogy.
ease, antibiotics may be considered, usually a penicillin D) Co ious irrig tion, syste ic ntibiotics, nd cyclo legi .
or cephalosporin.
Answer 1.9.1 The correct answer is “C.” T is is n o hth l o-
logic e ergency th t requires to ic l ntibiotics, cyclo legi
( or in control), nd re err l to n o hth l ologist. T ese
T e patient mentioned above has a “ riend” who was also in ulcers c n beco e quite dee nd result in ru tured globe.
the altercation. He, too, was just “minding his business”—
like everyone in the bar—until there was a gentleman’s dis- You consult with your ophthalmologist who would like you
agreement that could only be resolved with a broken bottle. start a cycloplegic agent in this patient prior to trans er.
He has a simple laceration o the chin, which you repair. T is
patient has a blood alcohol level o 150 mg/dL (the legal limit Question 1.9.2 The drug you would choose or a cycloplegic
in most states is 80 mg/dL). Since he is intoxicated, the nurses agent is:
are reluctant to allow the patient to leave because o liability A) Piloc r ine eye dro s.
issues. He seems initially very cooperative and competent. B) i olol eye dro s (e.g., i o tic).
However, the nurse manager reminds you o the legal issues. C) etr c ine eye dro s.
T e patient is getting more agitated; he wants to go home. D) Cyclo entol te eye dro s.

Question 1.8.7 Your response is: Answer 1.9.2 The correct answer is “D.”Cyclo entol te is the only
A) Sed te the tient with h lo eridol nd observe hi until cyclo legic gent listed bove. Cyclo legic gents r lyze the cili-
sober. ry uscle so the eye c nnot cco od te. Piloc r ine is iotic
B) Sed te the tient with benzodi ze ine nd observe hi gent. i olol is bet -blocker used in the tre t ent o gl uco .
until sober. etr c ine eye dro s re to ic l nesthetic. T us, “D” is the only

correct nswer. Other cyclo legic gents include ho o tro ine The correct answer is “B.” T is tient likely h s UV ker titis.
nd tro ine. However, these h ve rolonged e ect. T e others re not likely bec use they gener lly resent unil t-
er lly. In ddition, in the c ses o “A” nd “C,” they should res-
Question 1.9.3 I your patient just had a simple corneal ent directly er the event r ther th n 9 hours l ter, s in our
abrasion, you would not have had to think so hard! Regard tient.
ing corneal abrasions, you realize that: UV ker titis is ound in tients who re welders or h ve
A) P tching n eye er corne l br sion reduces in nd been out in the sun or n extended eriod o ti e ( t the be ch,
ro otes he ling. snow skiing [“snow blindness”], t nning bed, etc.). UV ker ti-
B) I to ic l ntibiotic is needed er l rge corne l br sion, tis gener lly resents s severe, bil ter l, eye in bout 6 to
gent icin o hth l ic oint ent is the drug o choice. 10 hours ollowing the ctivity. It is tre ted with cyclo legic
C) etr c ine is good to ic l nesthetic nd should be consid- gents nd in edic tion, o en requiring n rcotics.
ered or ho e use in tients with in ul corne l br sion.
D) P tients should void we ring cont ct lenses until the eye
h s been he led or t le st week. HELPFUL TIP:
Patients who have a oreign body in the eye ollowing
Answer 1.9.3 The correct answer is “D.” “A” is incorrect a high-speed injury (e.g., grinding wheel) should be as-
bec use tching n eye y ctu lly incre se in nd decre se sumed to have a globe per oration until proven other-
he ling. Whether or not to use tch should be tter o wise.
tient co ort only. “B” is incorrect bec use gent icin o h-
th l ic oint ent ( s well s other to ic l inoglycosides)
ctu lly reduces he ling o the corne , nd ntibiotics re not QUICK QUIZ: ORTHOPEDIC EMERGENCIES
necess ry unless there re signs o in ection. “C” is incorrect
bec use tients should never be sent ho e with to ic l nes- Which o the ollowing is ost co only ssoci ted with sig-
thetic. T ey reduce he ling nd c n le d to urther injury i ni c nt v scul r injury?
the tient, whose eyes re now insens te, continues h r ul A) Pubic r us r cture.
ctivity, rubs his/her eyes, etc. B) Knee disloc tion.
C) Shoulder disloc tion.
HELPFUL TIP: D) Elbow disloc tion.
To di erentiate a topical ophthalmologic problem rom E) Ankle disloc tion.
iritis, put in some tetracaine. I the pain resolves, it is
likely, but does not prove, that the problem is su- The correct answer is “B.” In u to 33% o knee disloc tions
per icial (e.g., corneal abrasion). Posttraumatic iritis is (not patellar dislocations), o lite l rtery injury c n be iden-
mani ested by ciliary lare, anterior chamber cells, and ti ed. It is deb ted s to whether ll tients with knee dislo-
marked photophobia. These patients really need a slit c tions require ngiogr hy or C ngiogr hy or i hysic l
lamp examination. ex in tion nd nkle-br chi l indices re su cient to rule out
o lite l rtery injury, but v scul r injury is jor c use o
Objectives: Did you learn to . . . li b loss nd orbidity. “A” is incorrect bec use ubic r us
• Recognize a corneal ulceration and treat it appropriately?
r ctures re rel tively inor injuries without v scul r involve-

ent, requiring only in control. Shoulder disloc tions (“C”)
Treat corneal abrasions?
re co only ssoci ted with injury to the xill ry nerve.
• Understand the proper use o cycloplegic agents?
Elbow disloc tions (“D”) c n be ssoci ted with injury to the
edi n nerve nd br chi l rtery. However, rteri l injuries re
QUICK QUIZ: EYE TRAUMA uch less co on th n with knee disloc tions. Ankle disloc -
tions (“E”) re r rely ssoci ted with v scul r injury.
You re on c ll or your grou nd welder who w s welding
nd grinding resents t 2:00 a m with severe bil ter l eye in.
When he le work t 5:00 pm the d y be ore, he did not notice
CASE 1.10
ny roble . He notes th t he w s we ring his d rk goggles A 55-year-old male armer is injured by a grass- ed cow
so e o the ti e while he w s welding but did quite bit o that pins him against a ence. His leg was trapped against
work without goggles s well. the ence or a several minutes. Being a typical Midwestern
armer, he ignores the injury until his wi e convinces him
T e ost likely di gnosis in this tient is: later that a ernoon to have it evaluated. He presents to your
A) Foreign body. o ce complaining o severe pain in the cal area. A radio-
B) Ultr violet (UV) ker titis. graph is normal, and the patient has normal distal pulses.
C) Globe enetr tion second ry to the welding nd oreign body. T e cal (his leg, not the cow) is tender with increased pain
D) Iritis. on passive stretch. His pain seems to be out o proportion to

his injury. T e cal (the cow) may also be tender and USDA co gul tion studies y be ro ri te de ending on the clini-
grade prime. c l situ tion but re not use ul in est blishing the resence o
yoglobinuri .
Question 1.10.1 Which o the ollowing is true?
A) Since the tient h s excellent ulses, co rt ent syn- HELPFUL TIP:
dro e is not likely. Myoglobin can be measured in the urine. However,
B) Co rt ent syndro e is de ned s co rt ent res- many laboratories have stopped doing this test avor-
sure >30 Hg. ing the positive dipstick/negative microscopic exami-
C) Co rt ent syndro e is only ssoci ted with signi c nt nation approach. There can be other causes of a heme
crush injuries or r ctures. positive dipstick. Thus, always check a CPK as well i
D) P in out o ro ortion to the injury is red g or co rt- rhabdomyolysis is a consideration.
ent syndro e.

Answer 1.10.1 The correct answer is “D.” P in out o ro or- T e patient has a positive dipstick or blood with no red blood
tion to the injury is red g or co rt ent syndro e. “A” cells on microscopic examination (presumptive myoglobin-
is incorrect bec use ulses c n be int ined until there is uria). His serum CPK is 32,000 U/L, which is well above ve
signi c nt incre se in co rt ent ressures nd signi c nt times the upper limit o normal (the cuto or consideration
injury to uscle nd nerves. “B” is incorrect bec use it is di - o rhabdomyolysis, although levels o > 15,000 U/L are com-
cult to de ne s eci c cut o or co rt ent syndro e. mon when one has symptomatic rhabdomyolysis), so you
So e tients toler te higher ressures nd others c nnot make the diagnosis o rhabdomyolysis.
toler te 30 Hg (nor l co rt ent ressure is zero).
However, when the ressure gets bove 20 to 30 Hg, strong Question 1.10.3 The most common adverse consequence
consider tion should be given to the resence o co rt ent and greatest danger o rhabdomyolysis is:
syndro e. “C” is incorrect. Co rt ent syndro e c n be A) Disse in ted intr v scul r co gul tion.
due to nu ber o ctors including electric l injury, exces- B) Acute kidney injury.
sive uscle use, tet ny, re er usion er ische i , ggressive C) Seizure ro hy oc lce i .
volu e resuscit tion, etc. D) Acute gout ro hy erurice i .
E) C rdi c rrhyth i ro hy erk le i .
The classic indings o arterial insu iciency (the “5 Ps” be- Answer 1.10.3 The correct answer is “B.” Myoglobin reci i-
ing pulselessness, paresthesia, pallor, pain, and paralysis) t tes in the ren l tubules c using cute kidney injury. “A,” DIC,
are o ten considered necessary or compartment syn- c n occur but is r re. “C,” seizures ro hy oc lce i , h ve not
drome to be diagnosed. This is incorrect. O these, pain is been re orted in this condition, nor h s “D,” gout. T e ot s-
o ten the only symptom; the second most requent would siu elev tion ro rh bdo yolysis y re ch level su cient
be paresthesia. I your patient has compartment syndrome to c use rrhyth i s; this is ex cerb ted by ossible coexistent
with the 5 Ps present, there is likely extensive injury. hy oc lce i .

Question 1.10.4 The primary treatment or rhabdomyolysis

You decide that it is likely that this patient has a compart- A) M nnitol in usion.
ment syndrome. B) S line in usion.
C) Furose ide.
Question 1.10.2 Which o the ollowing labs will be the D) Di lysis.
most help ul in guiding treatment or this patient?
A) CBC. Answer 1.10.4 The correct answer is “B.” T e ost i or-
B) Urin lysis. t nt tre t ent or rh bdo yolysis is s line in usion. L ct ted
C) Glucose. Ringers should be voided s it cont ins ot ssiu , which y
D) Sodiu . urther contribute to hy erk le i s entioned bove. T ere
E) P /P . h s reviously been deb te i lk liniz tion o the urine (using
IV sodiu bic rbon te) h s ny dditive bene t or revent-
Answer 1.10.2 The correct answer is “B.” One o the jor ing cute kidney injury over s line lone, but there is no evi-
co lic tions o co rt ent syndro e is rh bdo yolysis. dence th t su orts this r ctice. “A,” nnitol, c n be used to
T is will ni est itsel s urine which is di stick ositive incre se urine ow, but this is re lly tre t ent th t is second-
or blood but with neg tive icrosco ic ex in tion or red ry to good hydr tion nd y c use hy ovole i co ound-
blood cells. T e ositive di stick is icking u yoglobin in ing the roble “C,” urose ide, is controversi l nd h s no
the urine. Rh bdo yolysis c n be con r ed by seru level outco e bene t but c n be used or uid overlo d. “D,” di lysis,
o cre tine hos hokin se (CPK). CBC, glucose, sodiu , nd is wh t we re trying to void using s line.

chills, dys ne , r les, nd rhonchi. T e etiology is unknown, but

it y be second ry to in rction o the lung nd/or t e boli.
In adult patients with rhabdomyolysis, the goal is to
All o the other di gnoses should lso be entert ined t this
maintain urine output o 200 to 300 cc/hr.
oint, but cute chest syndro e is ost likely. Sickle cell-rel ted
eric rditis (“D”) is r re co lic tion o the dise se.

T e patient is able to maintain urine output a er you insti- Question 1.11.2 All o the ollowing are recommended in
tute saline. the initial treatment o acute chest syndrome EXCEPT:
A) Hydroxyure .
Question 1.10.5 What treatment are you going to suggest B) Oxygen.
or the underlying compartment syndrome? C) IV nor l s line.
A) F scioto y. D) Mor hine.
B) I obiliz tion nd tr ction.
C) Hot cks nd elev tion o the ected li b. Answer 1.11.2 The correct answer is “A.” Hydroxyure , while
D) Ice nd elev tion o the ected li b. use ul or the chronic tre t ent o sickle cell ne i , is not
indic ted or the tre t ent o cute chest syndro e. However,
Answer 1.10.5 The correct answer is “A.” T e tre t ent o it c n reduce the incidence o cute chest syndro e by 50%
co rt ent syndro e is scioto y. A r id surgic l or when used chronic lly. M n ge ent o cute chest syndro e
ortho edic consult tion is critic l in the tre t ent o co rt- includes llevi ting hy oxi (“B”), IV uid resuscit tion (“C”),
ent syndro e. nd ro ri te n lgesi (“D”). Other tre t ents include
IV ntibiotics to cover or co unity- cquired neu oni
T e patient does well and everyone is happy . . . except or the ( lthough cute chest syndro e is not bacterial). It is rudent
cow, who nds his way onto the table as the centerpiece o to cover these tients with ntibiotics bec use dult tients
Christmas dinner. with sickle cell re de cto s lenecto ized nd the initi l re-
Objectives: Did you learn to . . . sent tion o cute chest syndro e c n be e sily con used with
• Recognize mani estations o compartment syndrome and neu oni .
understand that compartment syndrome can be present
with pain alone? T e patient continues to be hypoxic despite your therapy. His
• Identi y patients at risk or compartment syndrome and CBC shows a slight elevation in the WBC count and a hemo-
rhabdomyolysis? globin o 9 g/dL. A chest radiograph indicates progression o
• Manage compartment syndrome? in ltrates.
• Diagnose and treat rhabdomyolysis?
Question 1.11.3 The next step in treating this patient is:
A) Fresh rozen l s .
CASE 1.11 B) Pentoxi ylline.
C) P cked red blood cells.
A 24-year-old A rican-American male presents to the ED D) Exch nge tr ns usion.
complaining o ever, chills, and dyspnea. He has chest pain E) Any o the bove.
that is respirophasic (“pleuritic”) in nature. He is noted to be
tachypneic with a respiratory rate o 36 and an oxygen satu- Answer 1.11.3 The correct answer is “D.” P tients with cute
ration o 90%. He has a history o sickle cell disease and has chest syndro e who re in hy oxic with rogressing in l-
had a number o sickle cell crises in the past. He is up to date tr tes re c ndid tes or exch nge tr ns usion to bring the level
on immunizations, including Streptococcus pneumoniae and o HbS to <30% o the tot l. Si ly d inistering blood (“C”)
Haemophilus inf uenzae vaccines. will not resolve the roble bec use HbS will still be resent in
signi c nt ounts. I this tient h d ore signi c nt ne-
Question 1.11.1 The patient’s current symptoms are MOST i , cked red cell tr ns usion would be ore vi ble o tion.
concerning or and suggestive o : But tr ns usion t level o 9 g/dL o he oglobin is not indi-
A) Pneu othor x. c ted (gener lly the threshold is 7 g/dL in the he odyn i-
B) Pul on ry e bolis . c lly st ble tient). “A” nd “B” re lso incorrect. Fresh rozen
C) Acute chest syndro e. l s h s no role in the tre t ent o cute chest syndro e,
D) Sickle cell-rel ted eric rditis. nor does entoxi ylline.
E) T or cic ortic neurys dissection.
Your patient recovers rom this episode. He has had numer-
Answer 1.11.1 The correct answer is “C.” T is tient likely h s ous pain crises in the past, as well as hospitalizations or other
cute chest syndro e, which is ssoci ted with sickle cell ne- reasons. You have an opportunity to provide some patient
i and may be indistinguishable rom pneumonia. Acute chest education. You answer a ew o your patient’s questions and
syndro e is ch r cterized by leuritic chest in, ever, cough, then review potential mani estations o sickle cell disease.

Question 1.11.4 Which o the ollowing may be a mani es

tation o sickle cell disease? CASE 1.12
A) Joint nd bone in. A 52-year-old truck driver presents to your ED a er being out
B) Acute bdo in l in. in subzero temperatures or several hours trying to repair his
C) Acute sequestr tion syndro e. truck. He is hypothermic when you use a low-reading rectal
D) A l stic crisis. thermometer with appropriate calibration (“T anks or
E) All o the bove. getting the most accurate temperature, doc!”). His initial core
temperature is noted to be 28◦ C. He has a pulse o 24 bpm, a
Answer 1.11.4 The correct answer is “E.” All o the bove c n BP o 70/30 mm Hg, and slow mentation. However, he is awake,
be ssoci ted with sickle cell ne i (kee re ding or ddi- and thus able to joke about a thermometer in his rectum.
tion l in or tion).
Question 1.12.1 The appropriate rst line treatment or
Question 1.11.5 Which o the ollowing in ections is a this patient’s pro ound bradycardia is:
common cause o aplastic crisis in sickle cell anemia? A) Atro ine.
A) P rvovirus B-19. B) E ine hrine.
B) In uenz virus. C) Do ine.
C) CMV virus. D) Lidoc ine.
D) P r in uenz virus. E) Re-w r ing.
E) None o the bove.
Answer 1.12.1 The correct answer is “E.” T e hy other ic
Answer 1.11.5 The correct answer is “A.” P tients with sickle he rt is gener lly resist nt to drugs. T us, the best tre t ent or
cell ne i c n develo l stic ne i in res onse to rvo- this tient is re-w r ing. Br dyc rdi ro other c uses c n
virus B-19 in ection. E stein–B rr virus nd so e b cteri h ve be tre ted with tro ine 0.5 g IV ush or in usion o e ine h-
lso been re orted to c use l stic crisis in tients with sickle rine or do ine.
cell ne i .
Question 1.12.2 All o the ollowing are acceptable meth
Question 1.11.6 Acute sequestration syndrome is a mani ods o re warming THIS patient EXCEPT:
estation o sickle cell anemia. In which group does acute A) Active extern l re-w r ing (e.g., hot cks).
sequestration syndrome occur? B) I ersion in 40°C w ter.
A) Younger th n 5 ye rs. C) P ssive extern l re-w r ing (e.g., bl nkets).
B) 5 to 12 ye rs old. D) He ted, hu idi ed oxygen.
C) 12 to 25 ye rs old. E) T or cic l v ge with w r uids.
D) Older th n 25 ye rs.
E) Older th n 65 ye rs. Answer 1.12.2 The correct answer is “C.” P tients with te -
er ture o below 30°C gener lly do not h ve enough endog-
Answer 1.11.6 The correct answer is “A.” Acute sequestr tion enous he t roduction to e ectively re-w r the selves.
syndro e occurs when the s leen sequesters red blood cells, le d- T us, extern l or intern l active re-w r ing is indic ted. All
ing to dro in he oglobin. T e resent tion c n be quite dr - o the other o tions re cce t ble ethods o re-w r ing this
tic with severe le u er qu dr nt in, s leno eg ly, nd tient. Extr cor ore l blood w r ing vi ECMO or di lysis
ro ound ne i , so eti es resulting in hy ovole ic shock nd long with thor cic c vity l v ge vi chest tubes nd w r crys-
de th. Bec use it requires unction l s leen, it is ost co on in t lloid re lso e ective. G stric, rect l, nd bl dder l v ge with
children younger th n 5 ye rs. P tient with sickle cell ne i who wr uids re gener lly not very e ective bec use o the li -
re older th n 5 ye rs gener lly do not h ve unctioning s leen; ited sur ce re involved nd c n c use l rge electrolyte shi s.
ost o en it h s in rcted so th t cute sequestr tion syndro e
no longer occurs. T e ort lity is 15% er e isode nd 50% recur. Question 1.12.3 Rapid re warming o the extremities is
associated with:
HELPFUL TIP: A) Alk losis, hy ok le i .
Exchange trans usions to reduce the percent o HbS to B) Acidosis, hy ok le i .
<30% is also indicated in stroke. Also keep the hemoglo- C) Acidosis, hy erk le i .
bin >9.0 g/dL in those with a sickle cell–related stroke. D) Alk losis, hy erk le i .
E) Mixed cid–b se disorder.
Objectives: Did you learn to . . . Answer 1.12.3 The correct answer is “C.” Re-w r ing o the
• Recognize acute chest syndrome? extre ities c n le d to return o cold blood to the core le ding
• Manage a patient with acute chest syndrome? to r doxic l dro in body te er ture. In ddition, hy o-
• Use exchange trans usion in a patient with sickle cell anemia? ther i c uses l ctic cidosis with hy erk le i in the extre -
• Recognize various other mani estations o sickle cell anemia? ities. As the eri her l blood is re-w r ed nd eri her l

v sodil tion occurs, the hy erk le ic, cidotic blood is obi- Answer 1.12.6 The correct answer is “E.” T e ro ri te
lized to the tient’s centr l circul tion, with result nt syste ic dosing o or hine in cute in is never-ending source o
et bolic cidosis nd hy erk le i . ze ent to our resident hysici ns who re er to st rt with
1 to 2 g IV. Nonetheless, the correct dose o IV or hine is
Question 1.12.4 Which o the ollowing is NOT associated 0.1 g/kg or 10 g in this 100 kg le. Si il rly, the correct
with an increased risk o hypothermia? dose o ent nyl is 1 µg/kg (100 µg in 100-kg dult) nd the
A) Di betes ellitus. dose o hydro or hone is 0.015 g/kg (1 to 2 g in 100-kg
B) Obesity. dult). However, there re lly is no “ xed” dose o n rcotic in
C) Alcohol use. edic tion in the ED. itr te the dose until you obt in in
D) Old ge. relie —with the tient still bre thing, we ho e.
E) Chronic illness.
It is 2 days later. T e patient is noted to have black eschar on
Answer 1.12.4 The correct answer is “B.”In Iow , we st rt to work multiple ngers and toes. T ere is no obvious per usion to
on our winter t l yer in October or just this re son. Why do you these areas.
think we e t ll th t c ndy corn? Obese tients h ve s ller
body ss to sur ce re r tio nd do not h ve n incre sed risk Question 1.12.7 The best course at this point is:
o hy other i . “C,” lcohol use, c uses tients to be rel tively A) Debride ent o the nonvi ble tissue.
insens te to cold (thus the ter “liquid j cket”), c uses eri h- B) Skin gr ing over o en re s er debride ent.
er l v sodil t tion, incre sing he t loss, nd c uses oor choices C) Observ tion or nu ber o weeks des ite the bl ck esch r.
(like not we ring re l j cket. Just t ke look t those young col- D) A ut tion o the nonvi ble dist l digits.
lege ootb ll ns in Nove ber without shirts!). T er oregul -
tion is i ired s we ge. T us, “D,” old ge, is ssoci ted with Answer 1.12.7 The correct answer is “C.” It c n t ke weeks or
gre ter ro ensity tow rd hy other i . Di betes (“A”) nd ny the ro er de rc tion line or debride ent nd gr ing to
chronic illness (“E”) c n lso redis ose to hy other i . beco e rent. T us, ggressive intervention t this oint is
counter roductive nd y le d to ddition l tissue loss. For
T e patient’s mental status clears and he complains that his n- this re son, “A” nd “D” re incorrect. Skin gr ing is lso not
gers and toes, which were numb and cold, are now quite pain- ro ri te t this ti e bec use debride ent o the esch r is
ul. You note that there is probably reezing o tissue ( rostbite). not ro ri te.
Objectives: Did you learn to . . .
Question 1.12.5 The best method o re warming the rost
• Identi y severe bradycardia in hypothermia and treat it
bite is:
A) Slowly in te id w ter.
• Manage a patient with hypothermia?
B) R idly in the hottest w ter he c n st nd (tested by you, o
• Use methods o re-warming and identi y complications o
course, to ensure th t there will be no burns).
C) Using hot ir source such s h ir dryer.
• Recognize risk actors or hypothermia?
D) Using oist he t vi he ting d.
• Diagnose and manage rostbite?
E) We ring ittens.

Answer 1.12.5 The correct answer is “B.” Frostbitten rts

should be re-w r ed s quickly s ossible in hot w ter between QUICK QUIZ: DANGER IN THE LAUNDRY ROOM
37°C nd 40°C. W ter te er ture cooler nd hotter th n this
c n le d to incre sed tissue loss. T e other ethods “A,” “C,” Which o the ollowing is true bout the ingestion o household
“D,” nd “E” re not reco ended. Do not re-warm parts that ble ch?
may become rozen again (e.g., i you re in the eld). Re- reez- A) P tients who drink household ble ch re t high risk o
ing will c use ddition l d ge. eso h ge l nd g stric burns.
B) Or l burns re good redictor o eso h ge l burns.
T e patient has a lot o pain a er thawing and reper usion. C) All tients who ingest household ble ch should be re erred
You control the pain with morphine. or u er endosco y to rule out burns.
D) Household ble ch ingestions re gener lly benign nd re-
Question 1.12.6 Which o the ollowing is the most appro quire no tre t ent i the tient is not sy to tic.
priate dose o morphine in this hemodynamically stable
100 kg male? The correct answer is “D.” Most household ble ch ingestions
A) 2 g IV. re benign nd need no ther y i the tient is sy to tic.
B) 4 g IV. However, this does not extend to industrial bleach or drain
C) 6 g IV. cleaner. T ere is high risk o eso h ge l nd g stric burns
D) 8 g IV. with industri l ble ch. “B” is incorrect. T e or l ucos y
E) 10 g IV. be nor l in industri l ble ch or dr in cle ner ingestion nd

there y still be signi c nt eso h ge l nd g stric burns. For is less ev or tive sur ce re er kilogr o weight. All o
this re son, ll tients with dr in cle ner or industri l ble ch the others redis ose to he t-rel ted illness. “A” nd “C” reduce
ingestion should undergo u er endosco y. “C” is incorrect; swe ting nd, in the c se o “A,” incre se et bolic r te. Both
tients with household ble ch ingestions do not require u er o these redis ose to he t-rel ted dise se. O rticul r note is
endosco y. “E.” S ll children swe t less re dily th n do dults. T is redis-
oses the to he t-rel ted dise se, but kes the less stinky
CASE 1.13 th n dults. T e elderly do not h ve the s e co ens tory
bility s younger eo le.
An 18-year-old male was working outside in the heat and
humidity. T e outside temperature reached 105°F with 90% HELPFUL TIP:
humidity. He usually lives in northern Canada and works or Up to 80% o patients with heat stroke will not have a
the government tracking the migration o caribou—but he is prodrome o nausea, lightheadedness, con usion, head-
here in Iowa on a job detasseling corn. (Don’t believe it? Look ache, etc., which is seen in heat exhaustion. Make sure
at www.teamcorn.com—seasonal hard work that pays well.) you check hepatic enzymes in patients in whom you
His riends noticed that he became con used, complained o suspect heat stroke. They are almost uni ormly elevated
a headache and muscle cramps, and became light-headed. On (beware they may take several hours to rise) and nor-
arrival to your ED, he is not sweating and is lethargic. His mal liver enzymes should cause you to question your
rectal temperature is 41.5°C. He says with a smile, “Guess I diagnosis.
just can’t handle the heat, eh?”

Question 1.13.1 All o the ollowing are indicated in the Objectives: Did you learn to . . .
treatment o this patient EXCEPT: • Recognize and manage heat exhaustion/heat stroke?
A) P ck the tient in ice to reduce core te er ture. • Recognize risk actors or heat exhaustion/heat stroke?
B) IV uids.
C) Use n nd s r y w ter on the tient to ro ote ev o-
r tive cooling.
D) Ad inister glucose i the tient is hy oglyce ic.
CASE 1.14
A 19-year-old emale presents to the ED with complaints o
Answer 1.13.1 The correct answer is “A.” P cking tients in wheezing. She has a history o asthma and you have been
ice is contr indic ted. ot l body i ersion in ice water is use- ollowing her since her eighth birthday, when her mother
ul but cking the erson in ice ctu lly reduces cooling or noticed that she couldn’t blow out her candles. In general,
two re sons. First, it c uses cut neous v soconstriction. Second, she has mild asthma not requiring an inhaled steroid. How-
it does not llow conductive cooling such s would be seen in ice ever, over the past several months, things have accelerated so
w ter sub ersion: solid ice does not h ve s uch skin cont ct that she now uses her rescue inhaler daily. On examination,
s w ter or the circul tion to conduct w y the he t. Re e ber she is tachypneic, using accessory muscles o respiration with
th t sub ersion in ice is lso ssoci ted with c using hypother- a respiratory rate o 30 and wheezing in all elds. Her oxy-
i .T e ro ri te tre t ent o he t exh ustion/he t stroke gen saturation is 95% and pulse is 110 bpm with a normal
(he t stroke being de ned s CNS dys unction with ch nge BP. Her blood gas is as ollows: pH 7.40, CO2 40 mm Hg, O2
in the level o consciousness) is cool w ter-so ked bl nkets 80 mm Hg, and HCO3 24 mEq/L.
nd towels with ns i ed t the tient. T is llows ev or -
tive cooling nd lso conductive he t loss (to the w ter in the Question 1.14.1 A normal blood gas in this patient sug
towels). Anti yretics re gener lly not e ective bec use by this gests that:
oint, the tient’s endogenous ther oregul tion is k ut. A) T is is ild ex cerb tion th t should res ond well to ther-
Question 1.13.2 Which o the ollowing IS NOT a contribut B) She h s res ir tory cidosis.
ing actor to heat exhaustion/heat stroke? C) She h s res ir tory lk losis.
A) Use o sti ul nts such s e hedr or het ines. D) T is is severe ex cerb tion th t will require ggressive
B) Dehydr tion. ther y.
C) Anticholinergic drugs. E) T is is nor l blood g s; she c n be disch rged.
D) T in body h bitus.
E) Extre es o ge. Answer 1.14.1 The correct answer is “D.” A H o 7.4 with
CO2 o 40 Hg in tient who is sth tic nd t chy neic
Answer 1.13.2 The correct answer is “D.” T is is why Iow ns is b d sign. T e CO2 should be low in t chy neic tient
st rt to work on their swi suit gures in A ril—it’s t- bec use they will be blowing o CO2. T us, nor l CO2 nd
ter o li e-or-de th, not n rcissis . A thin body h bitus is not nor l H indic te th t the tient is ret ining CO2. T is is
risk ctor or he t stroke/exh ustion; the o osite is true. just nother c se where looking t the tient is ore i or-
Obesity redis oses to he t stroke/exh ustion bec use there t nt th n looking t the l bs. Even though the blood g s itsel is

technic lly within nor l li its, this tient clinic lly e rs Answer 1.14.4 The correct answer is “E.” Albuterol c n be
sick. “B” nd “C” re both incorrect, since the blood g s indi- d inistered vi nebulizer continuously i needed, even in the
c tes neither n cidosis nor lk losis. edi tric ge grou . chyc rdi , one o the in side e ects
o lbuterol tre t ent, will o en improve with continuous
Question 1.14.2 Which o the ollowing tests are indicated in lbuterol. T is occurs bec use the tient’s t chyc rdi is o en
routine evaluation o a patient with an asthma exacerbation? driven by hy oxi . Once the sth is dequ tely tre ted, oxy-
A) Chest x-r y. gen tion i roves, nd the ulse co es down.
C) Arteri l blood g s. T e patient does not respond well to albuterol alone, so you
D) All o the bove. request the addition o ipratropium. At this point, you also
E) None o the bove. want to order steroids.

Answer 1.14.2 The correct answer is “E.” None o the bove Question 1.14.5 Which o the ollowing statements about
tests re indic ted in the routine ev lu tion o n sth ex c- steroid use in asthma exacerbation is true?
erb tion. A chest x-r y should be reserved or those tients in A) IV steroids re su erior to PO steroids in the tre t ent o
who neu oni or other ul on ry rocess is sus ected. A sth .
CBC is not going to ch nge your ther y in the routine sth B) All tients who re steroid de endent should h ve ddi-
ex cerb tion nd is not indic ted. Likewise, n ABG is unnec- tion l syste ic steroids even i they h ve lre dy t ken their
ess ry in ost sth ex cerb tions. It c n be used to ssist in dose or the d y.
your clinic l ev lu tion to deter ine whether or not the tient C) T e e ective dose r nge or steroids in sth is well est b-
is ret ining CO2; however, even in the “cr shing tient,” n lished.
ABG is not necess ry bec use intubation is a clinical decision D) Only tients requiring d ission should h ve or l or r-
and should not be based on the blood gas. enter l steroids.

Question 1.14.3 You decide to initiate therapy or this Answer 1.14.5 The correct answer is “B.” All tients who re
patient. O the ollowing options, the initial treatment o steroid de endent should get steroids i they resent to the ED
this patient is: with n cute ex cerb tion o sth . “A” is incorrect. IV ste-
A) Subcut neous e ine hrine. roids nd or l steroids h ve the s e e c cy in cute sth
B) Albuterol MDI ( etered-dose inh ler) with s cer. ex cerb tions. T us, the choice o route de ends ostly on
C) Nebulized i r tro iu . convenience nd cost. “C” is incorrect. Multi le steroid dosing
D) Or l steroids. regi ens nd r nges o doses h ve been used in sth with
E) IV steroids. success. “D” is incorrect. Disch rged tients who h ve ny-
thing ore th n inor sth ex cerb tion should receive
Answer 1.14.3 The correct answer is “B.” T e initi l tre t ent steroids.
or this tient— nd ny tient resenting with n sth
ex cerb tion—is bronchodil tor. A bet - gonist is re erred, HELPFUL TIP:
in this c se lbuterol. It kes little di erence whether this is When compared with oral steroids, IV steroids may in-
vi nebulizer or MDI, s long s one uses dequ te doses. One crease hospitalizations, cost, and treatment ailure in
lbuterol nebuliz tion is equ l to bout 8 to 10 u s o n lb- those with chronic obstructive pulmonary disease. Use
uterol MDI with s cer. “A” is incorrect bec use subcut neous oral steroids whenever possible; the bioavailability is
e ine hrine is second or third line in the tre t ent o sth . high (JAMA. 2010;303(23):2359–2367).
“C” is incorrect. While i r tro iu is e ective in sth , it is
second ry to lbuterol in the tre t ent o sth . “D” nd “E”
re incorrect. Steroids re indic ted, but bronchodil tor ther y Question 1.14.6 Which o the ollowing is true about the
is the ri ry tre t ent in cute sth ex cerb tions. role o theophylline in the treatment o acute asthma
T ere is no albuterol MDI available to you in your ED, so the A) heo hylline/ ino hylline should be used in c ses
patient receives nebulized albuterol. However, she continues unres onsive to two to three doses o nebulized lbuterol
to wheeze. since it h s dded bene its when used with n inh led
bet - gonist.
Question 1.14.4 How many albuterol treatments can this B) P tients who get theo hylline/ ino hylline h ve ore
patient sa ely receive? side e ects th n do tients who get continuously nebulized
A) One every other hour. lbuterol nd get no bene t ro the drug.
B) One er hour. C) I you choose to use theo hylline/ ino hylline, the ther -
C) wo er hour. eutic go l is seru level o 150 µg/dL.
D) T ree er hour. D) T eo hylline/ ino hylline h s side e ect ro le su e-
E) Continuous nebuliz tion o lbuterol is s e. rior to bet - gonists like lbuterol.

Answer 1.14.6 The correct answer is “B.” P tients who re Objectives: Did you learn to . . .
tre ted with theo hylline h ve ore side e ects, including • Recognize clinical and blood gas mani estations o a severe
t chyc rdi , n use , nd rrhyth i s, th n do tients who get asthma exacerbation?
continuously nebulized lbuterol (“D” is incorrect). T eo hyl- • Evaluate a patient presenting with an asthma exacerbation?
line/ ino hylline h s essenti lly no role in the tre t ent o • Initiate treatment or asthma in the ED?
cute sth ex cerb tions. T ere is no bene t to theo hyl- • Recognize the pit alls in using theophylline/aminophylline
line or ino hylline over optimal bet - gonist ther y (e.g., or asthma?
continuous nebulized lbuterol i required). “C” is incorrect • Formulate a plan or discharging an asthma patient rom the
bec use i used t ll, the ther eutic go l or theo hylline is ED?
seru level o 15 µg/dL.
CASE 1.15
A 7-year-old presents to the ED with wheezing and hives a er
Magnesium sul ate (2 g over 10 minutes in adults,
being stung by a “bee.” He was evidently throwing rocks at
25 mg/kg in children) can be used in patients with sta-
a yellow-jacket nest when he was stung, so at least he hope-
tus asthmaticus. Magnesium is a direct smooth muscle
ully learned something. On examination, the patient has
relaxant. Not all patients will respond, and in patients
hives and wheezing with a normal BP or his age. He is mildly
who will respond, you can expect a 60- to 90-minute
e ect. Avoid using magnesium in patients with renal
ailure since they may become toxic.
Question 1.15.1 Potentially use ul treatments or this patient
include all o the ollowing EXCEPT:
A) IV di henhydr ine.
T e patient responds to nebulizers and steroids. You decide B) Intr uscul r (IM) e ine hrine.
to send her home. C) Subcut neous (SC) di henhydr ine.
D) IV ci etidine.
Question 1.14.7 Which o the ollowing is true?
A) You should disch rge the tient on 2 u s o n lbuterol Answer 1.15.1 The correct answer is “C.” Subcut neous
MDI vi s cer to be used PRN. di henhydr ine c n c use skin necrosis nd is contr indi-
B) You should l ce the tient on steroid, t ering the dose c ted. Either IV or IM di henhydr ine c n be used. O the
over 3 weeks. others, intramuscular (not SC) e ine hrine should be used in
C) You should disch rge the tient on 8 to 10 u s o n lb- the tient with n hyl xis; it is the drug o choice or n hy-
uterol MDI vi s cer to be used every 6 hours round the l xis. Re e ber th t di henhydr ine will not reverse bron-
clock. chos s or hy otension. Subcut neous e ine hrine is err ti-
D) You should st rt the tient on steroid inh ler. c lly bsorbed. I hy otension ersists des ite IM e ine hrine
E) You should st rt the tient on long- cting bronchodil tor nd IV uids, IV e ine hrine should be d inistered. Intr ve-
inh ler. nous H2 blockers (e.g., ci etidine, r nitidine) re rticul rly
e ective in the tre t ent o n hyl xis nd should be used
Answer 1.14.7 The correct answer is “D.” T e tient should be routinely in these tients, lso.
st rted on steroid inh ler to revent recurrent ex cerb tions.
She h s been using her lbuterol d ily, indic ting oor control.
Overl ing this with or l steroids will give the inh led steroid HELPFUL TIP:
ch nce to work while the tient is being covered with the or l Only honeybees generally leave a stinger. Remove it by
steroids. “A” is incorrect. One nebuliz tion is equ l to 8 to 10 any means possible. The amount o envenomation is
u s o n MDI. I you si ly go b ck to low-dose lbuterol, the directly proportional to the amount o time the stinger
tient is ore likely to do oorly. We tend to underdose lb- is in the skin and not to how you remove it (credit card,
uterol inh lers; tients c n s ely t ke ore th n 2 u s. “B” is orceps, etc.).
incorrect bec use tients do not need a steroid taper i they re
not on chronic steroids nd will not be t king steroids or ore
th n 10 d ys. You c n si ly tre t the tient (e.g., with red- T e patient responds well to the therapy as noted earlier. You
nisone 40 g PO QD or 5–10 d ys) nd then sto . No t er is are going to discharge him and want to write his prescriptions.
needed. Note that this is not true or patients on chronic steroids
who clearly do need a taper. “C” is incorrect bec use scheduled Question 1.15.2 The patient should be discharged with
lbuterol is not s e ective s PRN use. In ddition, lbuterol which o the ollowing?
c n cert inly be used ore th n every 6 hours. “E” is incorrect A) Di henhydr ine Q 6 hours or the next 48 hours.
bec use long- cting inh led bronchodil tor ther y should not B) Ci etidine Q 12 hours or the next 48 hours.
be used lone in sth due to the otenti l to incre se ort l- C) An n hyl xis (“bee sting”) kit.
ity; it should only be used with n inh led steroid. D) All o the bove edic tions.

Answer 1.15.2 The correct answer is “D.” P tients c n h ve Vital signs: temperature 37.0°C, pulse 110 bpm, respira-
bi h sic re ction edi ted by “slow re cting subst nce o n - tions 18, and BP 120/85 mm Hg. He is in distress secondary
hyl xis” which is now believed to be neutro hil che ot ctic to pain. Abdomen: normal bowel sounds, nontender, so , no
ctor. T is recurrence y occur u to 48 hours er the initi l masses. Genitourinary: circumcised male, no penile lesions,
event. T us, rescribing edic tions to revent the recurrence no discharge. T e le testicle is tender to palpation and has a
is rudent. Also, the tient should h ve “bee sting” kit v il- normal lay in the scrotum. T e cremasteric ref ex is normal
ble, which should include re- lled syringe or e ine hrine bilaterally.
injection (e.g., E i-Pen or E i-Pen Junior). It is reco ended
th t tients h ve two syringes v il ble t ho e s the ilure Question 1.16.1 What is the signi cance o the normal lay
r te with one injection is irly high. and cremasteric ref ex?
A) T e cre steric re ex should be bnor l in e ididy itis.
T e parents are concerned about this child who likes to play B) T e resence o cre steric re ex e ectively rules out tes-
outside. T ey worry that he will get stung again. ticul r torsion.
C) T e nor l l y o the testicle in the scrotu e ectively rules
Question 1.15.3 You let them know that: out testicul r torsion.
A) Any sting should be tre ted s n e ergency. D) T e resence or bsence o cre steric re ex is not hel ul
B) He will continue to be llergic to “bee stings” in the uture. in ruling out testicul r torsion.
C) He should t ke ro hyl ctic edic tion be ore going out to
l y in the woods or other re s where he ight get stung. Answer 1.16.1 The correct answer is “D.” T e resence or
D) None o the bove. bsence o cre steric re ex (cre steric contr ction with
elev tion o the testis in res onse to stroking o the s e side
Answer 1.15.3 The correct answer is “D.” Here is why. P tients u er thigh) is neither sensitive nor s eci c enough to con r
who re llergic to one s ecies o hy eno ter n re not neces- or rule out the resence o testicul r torsion. Likewise, the l y o
s rily llergic to others. In gener l, the llergy is s ecies s eci c. the testicle c n be nor l in tients with testicul r torsion. An
T us, ost stings will be benign in n llergic tient unless it is bnor l testicul r l y nd the bsence o the cre steric re ex
sting ro the o ending s ecies. “B” is incorrect. M ny chil- y oint tow rd testicul r torsion. However, you c nnot rely
dren tend to “outgrow” “bee sting” llergies. T is is in contr st on these ndings to rule out testicul r torsion.
to dults in who re ctions tend to get worse over ti e. “C” is
incorrect. Obviously the child should be c re ul not to irrit te Question 1.16.2 The LEAST likely diagnosis in this patient
yellow j ckets (did ny o you hurl rocks t w s nests s kid?), is:
but ro hyl ctic tre t ent is not routinely indic ted. A) orsion o testis.
B) E ididy itis.
HELPFUL TIP: C) orsion o endix testis.
Adults with a systemic allergic reaction to an insect D) orsion o endix e ididy is.
sting have a 30% to 60% risk o experiencing another E) esticul r tu or.
systemic reaction upon being stung again. There ore,
adults are more likely to bene it rom venom testing Answer 1.16.2 The correct answer is “E.” esticul r torsion is
and prophylaxis (which can reduce the risk to 5%). All ch r cterized by cute onset o unil ter l testicul r in, o en
patients with a history o anaphylaxis should be pro- during ctivity such s running. It h s bi od l ge distribution,
vided with an anaphylaxis kit. during the rst ye r o li e nd g in during uberty. T e di er-
enti l di gnosis is de endent on the tient’s ge. I the tient is
younger th n 15 ye rs, the di erenti l consists o testicul r tor-
Objectives: Did you learn to . . . sion, e ididy itis, torsion o endix testis or endix e idid-
• Describe the physiology and natural course o bee sting y is, orchitis, hydrocele, nd v ricocele. In tients older th n
reactions? 15 ye rs, the di erenti l includes ll o these di gnoses lus tes-
• Treat a patient with an anaphylactic reaction to a bee sting? ticul r tu or. However, testicul r tu ors re gener lly inless.

Question 1.16.3 What is the most reliable method or diag

CASE 1.16 nosing testicular torsion?
A) Do ler (Du lex color).
A 14-year-old otherwise healthy male presents to the ED B) R dionuclide sc n.
with acute onset le testicular pain when running 1 hour C) Surgic l ex lor tion.
prior to presentation. He denies any trauma to the region. He D) X-r y.
states that his pain is severe and only on the le . T e pain is E) MRI.
increased with ambulation and movement. He has had nau-
sea and vomiting. He denies diarrhea, ever, chills, dysuria, Answer 1.16.3 The correct answer is “C.” Every patient with
hematuria, or penile discharge. suspected testicular torsion should have surgical exploration o

the scrotum. All o the other studies re djunctive. For ex - hematuria, ever, chills, vaginal discharge, nausea, vomiting,
le, r dionuclide sc n y result in lse-neg tive nd t kes or diarrhea. Her last menses was 2 weeks ago, and she states
sever l hours to er or . Ultr sound h s sensitivity s low s she is not sexually active. She is on oral contraceptives to treat
82%. Surgic l ex lor tion is the only de nitive di gnostic tool. menstrual cramps and denies any allergies.
T e window o o ortunity or surgery is bout 6 hours, er
which the testicle y not be s lv ged. Orchio exy should be Question 1.17.1 A urine beta HCG is NOT indicated or
er or ed on the involved nd uninvolved sides to revent tor- which o the ollowing patients who presents with abdomi
sion. M nu l detorsion c n be tte ted nd requires sed tion nal pain?
nd in edic tions. wist testis like you re o ening book A) A 32-ye r-old e le who h s h d tub l lig tion.
(the right testis counterclockwise nd the le clockwise). I in B) A 16-ye r-old e le who by history h s never been sexu lly
resolves, you h ve detorsed the testis. ctive.
C) A 25-ye r-old e le who h s h d nor l eriod 1 week
Objectives: Did you learn to . . .

go nd swe rs on st ck o Bibles th t she couldn’t ossibly
Examine a patient presenting with acute scrotal pain?
be regn nt.
• Generate a dif erential diagnosis or scrotal pain based on
D) A 24-ye r-old, rried, ro ession l e le who is t king
the patient’s age?
or l contr ce tives nd h d nor l l st enses.
• Evaluate a patient with suspected testicular torsion?
E) A 25-ye r-old le.

QUICK QUIZ: UROLOGIC INFECTION 1 Answer 1.17.1 The correct answer is “E.” O course les do
not need regn ncy test ( lthough the HCG y be elev ted
in testicul r c ncer). All e le tients o re roductive ge,
Wh t is the ost co on gent c using e ididy itis in
exce t or those who h ve h d hysterecto y, ust h ve reg-
21-ye r-old le?
n ncy test s rt o the ev lu tion o bdo in l in. T ere re
A) Escherichia coli.
sever l re sons or this osition. First, ny tients y not be
B) Neisseria gonorrhoeae.
c ndid bout their sexu l ctivity. In ct, in one study, l ost
C) Chlamydia trachomatis.
one-third o tients who s id “they could not ossibly be reg-
D) Pseudomonas s ecies.
n nt,” including one who denied ever h ving intercourse, were
E) Ureaplasma urealyticum.
regn nt. Second, the ilure r te o tub l lig tion is u to 5%
over 10 ye rs de ending on the technique used (l rosco ic
The correct answer is “C.” In young les, e ididy itis is
tub l lig tion is the le st reli ble). o r ise your concern little
usu lly the result o sexu lly tr ns itted dise ses. O these,
higher, l ost ll o the regn ncies in tients who h ve h d
C. trachomatis is currently the ost co on etiologic gent.
tub l lig tion re ecto ic.
N. gonorrhoeae is second ost co on in this ge grou . It is
there ore essenti l to tre t or both gents when the di gnosis o
e ididy itis is sus ected.
When examining a patient whose history is consistent
QUICK QUIZ: UROLOGIC INFECTION 2 with vulvovaginitis, remember that a KOH preparation
is only 65% to 80% sensitive or Candida and treatment
Wh t is the ost co on gent c using e ididy itis in based on symptoms and physical indings is certainly
55-ye r-old le? reasonable.
A) E. coli.
B) N. gonorrhoeae.
C) C. trachomatis.
You get a urinalysis (UA) on this patient, mostly out o habit.
D) Pseudomonas s ecies.
T e UA shows 5 to 10 WBCs/HPF, 2 + bacteria, 2 + leukocyte
E) U. urealyticum.
esterase, and 1 + nitrite.
The correct answer is “A.” Gr -neg tive rods re the ost
Question 1.17.2 Which o the ollowing antibiotic regimens
co on c use o e ididy itis in older en. O these, E. coli
IS NOT indicated or the treatment o simple cystitis?
is the ost co on etiologic gent, ollowed by Klebsiella nd
A) 3-d y course o tri etho ri –sul ethox zole ( MP–SMX).
Pseudomonas s ecies.
B) 3-d y course o uoroquinolone.
C) 5-d y course o nitro ur ntoin.
D) Single dose o os o ycin.
CASE 1.17 E) Single dose o ce h lexin.
A 22-year-old otherwise healthy emale college student pres-
ents to the ED with dysuria and urinary requency o 2 days Answer 1.17.2 The correct answer is “E.” T e usu l c us tive
duration. She denies any abdominal/pelvic pain, f ank pain, gents or unco lic ted cystitis re Gr -neg tive org nis s

such s E. coli. In re s th t h ve high r tes o resist nce to Question 1.18.1 What is the most likely diagnosis in this
MP–SMX (>30% or ore o isol ted E. coli b cteri resist nt), patient?
it is wise to use quinolone s the rst-line gent; however, qui- A) Pyelone hritis.
nolones re ore costly nd quinolone resist nce is rising. All B) Perirect l bscess.
o the bove regi ens re usu lly e ective or tre ting cystitis C) E ididy itis.
exce t single dose o ce h lexin. Ce h lexin is e ectively used D) Acute rost titis.
in regn nt e les, lthough 7-d y course is reco ended. E) Cystitis.
Fos o ycin h s lower cure r te th n the other regi ens nd
is ore ex ensive. Answer 1.18.1 The correct answer is “D.” T is tient’s sy -
to s ost closely t those o so eone with cute rost titis.
Although his UA is lso consistent with yelone hritis or cysti-
HELPFUL TIP: tis, his ex in tion ndings re ore suggestive o cute ros-
A alse-negative urinalysis is common in women with t titis. He l cks costovertebr l ngle tenderness ( yelone hri-
uncomplicated cystitis. Empiric treatment o urinary tis), nd he h s signi c nt te er ture th t rgues g inst
tract in ection (UTI) is reasonable in a emale o child- si le cystitis. In the st, rost tic ss ge w s reco ended
bearing years presenting with one or more typical when obt ining urine s eci en; but this r ctice is to be
symptoms (urgency, requency, dysuria) and no vaginal voided since it is quite in ul nd b cteri l seeding into the
discharge. bloodstre y occur. In the bsence o scrot l tenderness,
e ididy itis is lso quite unlikely.

Question 1.17.3 All o the ollowing patients with pyelone Question 1.18.2 What should be included in the treatment
phritis should be admitted EXCEPT: regimen or this patient?
A) A 22-ye r-old G1 P0 e le <24 weeks o gest tion, he o- A) Or l uoroquinolone or MP–SMX or t le st 3 weeks.
dyn ic lly st ble. B) Instructions or hydr tion, sitz b ths, stool so eners, nd
B) A 22-ye r-old e le un ble to toler te PO uids or edic tions. nonsteroid l nti-in tory drugs (NSAIDs).
C) A 22-ye r-old e le with unreli ble soci l situ tion nd/or C) Ad ission or IV ntibiotics i he e rs toxic or he ody-
co li nce. n ic lly unst ble.
D) A 22-ye r-old e le with n uncle r di gnosis or extre e D) Foley or su r ubic c theter i urin ry retention is rob-
in. le .
E) All o the bove.
Answer 1.17.3 The correct answer is “A.” T e old d ge th t ll
regn nt tients with yelone hritis ust be d itted h s gone Answer 1.18.2 The correct answer is “E.” P tients with cute
out o vor. It is s e to send tients ho e who re <24 weeks rost titis should be tre ted or t le st 3 weeks with or l ntibi-
o gest tion, co li nt, h ve st ble vit l signs, nd re cces- otics to revent chronic rost titis; so e suggest u to 42 d ys.
sible by tele hone. P tients should be given cle r instructions to re t ent should be initi ted with quinolone while urine cul-
return or ny co lic tions. All o the other situ tions require tures re ending, since sul resist nce is high in so e re s o
in-hos it l c re. the country.
Objectives: Did you learn to . . .
• Decide which patients should have a urine beta-HCG in the ED? While this patient is still in the ED, he develops acute uri-
• Provide appropriate antibiotic treatment to a patient with an nary retention. A Foley catheter is placed without di culty
uncomplicated UTI? and 300 cc o slightly cloudy urine is obtained. Your patient
• Identi y patients with pyelonephritis who require hospital eels much better and thanks you or alleviating his pain.
admission? You decide to discharge him home with the Foley catheter
and a leg bag a er discussion with a urologist and ollow-up
CASE 1.18
Question 1.18.3 Which o the ollowing cause urinary reten
A 63-year-old male presents to the ED with a 2-day history o tion in men?
ever, urinary requency, dysuria, and di culty initiating the A) Phi osis, urethr l stricture, benign rost tic hy er l si
urinary stream. He also relates having some perineal pain. (BPH), c lculi.
On examination, his vitals are stable except or a temperature B) Anticholinergics, sy tho i etics, n rcotics, nti sychotics.
o 38.5°C. His rectal examination is remarkable or a tender, C) Psychogenic.
warm, edematous prostate. T ere are no perirectal masses D) C ud equin syndro e, di betes, s in l cord injuries.
and the stool is heme negative. He has no penile lesions, dis- E) All o the bove.
charge, scrotal masses, or tenderness. He does not exhibit
any costovertebral angle tenderness. His UA is positive or Answer 1.18.3 The correct answer is “E.” All o the bove c n
10 WBCs/HPF, 1+ nitrite, 1+ leukocyte esterase. c use urin ry retention in en. By r, the ost co on c use

o cute urin ry retention is BPH. T e c tegories o cute urin ry uncircu cised les by the ge o 3 to 5 ye rs. Be ore this, no
retention y be divided into neurogenic (s in l cord injuries, ction need be t ken.
c ud equin syndro e, di betes, syringo yeli , etc.), obstruc-
tive (BPH, hi osis, r hi osis, c lculi, urethr l stricture, CASE 1.19
etc.), h r cologic ( nticholinergics, ntihist ines, n rcot-
ics, nti sychotics, tricyclics, etc.), nd sychogenic, which is A 20-year-old emale presents to your ED complaining o
di gnosis o exclusion. lower quadrant abdominal pain. She is on “the ring” or con-
traception and has been aith ully using it. She has had regu-
HELPFUL TIP: lar menses and has not noticed any change in her pattern o
Sending patients home on an alpha-blocker (e.g., doxa- menses. Her pain had a sudden onset but is not associated
zosin, tamsulosin) may reduce the need or re-catheter- with any vaginal bleeding. On vaginal examination, you nd
ization a ter the catheter is removed. marked cervical motion tenderness but no palpable adnexal

Objectives: Did you learn to . . . Question 1.19.1 Based on this in ormation you decide that:
• Recognize the clinical presentation o prostatitis? A) T e bsence o n dnex l ss e ectively rules out ecto ic
• Treat a patient with prostatitis? regn ncy.
• Identi y causes o urinary retention in a male? B) I tient beco es regn nt, ll or s o contr ce tion
reduce the risk o ecto ic regn ncy.
C) T e ct the tient h s h d nor l eriods e ectively rules
QUICK QUIZ: FORBIDDEN FORESKIN out n ecto ic regn ncy.
D) Cervic l otion tenderness e ectively clinches the di gno-
Which o the ollowing is ch r cterized by swollen, in ul sis o elvic in tory dise se.
oreskin th t c nnot be reduced b ck to its nor l osition? E) None o the bove is true.
A) Phi osis.
B) P r hi osis. Answer 1.19.1 The answer is “E,” none o the above. “A” is
C) B l no osthitis. incorrect bec use only 10% o tients with n ecto ic reg-
D) Me t l stenosis. n ncy will h ve l ble ss in the dnex . “B” is incorrect
bec use both intr uterine devices nd tub l lig tion increase
The correct answer is “B.” P r hi osis is condition in which the risk o ecto ic regn ncy i the tient beco es regn nt.
the oreskin is retr cted, swollen, nd un ble to reduce into its “C” is incorrect bec use 15% to 20% o tients with ecto ic
nor l osition. Ice nd ste dy nu l co ression o en er- regn ncy h ve no history o issed enses. “D” is incorrect
its reduction. Surgery is indic ted i nu l reduction ils. “A,” bec use cervic l otion tenderness c n be resent not only in
hi osis, is condition in which the dist l oreskin is too tight elvic in tory dise se but lso in other illnesses such s
to be retr cted to llow ex osure o the gl ns. It is o en con used ov ri n torsion, ecto ic regn ncy, etc.
with enile dhesions in those younger th n 2 ye rs. “C,” b l no-
osthitis, is or o cellulitis involving the oreskin nd gl ns in Question 1.19.2 Risk actors or ectopic pregnancy include
the uncircu cised le ssoci ted with oor hygiene. re t ent all o the ollowing EXCEPT:
is with w r so ks, ntibiotics, nd ossible circu cision. “D,” A) Prior ecto ic regn ncy.
e t l stenosis, is co on in circumcised les, ssoci ted with B) Or l contr ce tive use.
n in tory re ction involving the e tus. Sy to s th t C) History o elvic in tory dise se.
indic te the need or surgic l tre t ent include s r ying o the D) re t ent or in ertility.
urine stre or dors l de ection o the stre . E) Current intr uterine device use.

Answer 1.19.2 The correct answer is “B.” All o the others

QUICK QUIZ: FORESAKEN FORESKIN incre se the risk o n ecto ic regn ncy. Other risk ctors
include cig rette s oking, recent elective bortion, revious
Until wh t ge is it nor l to h ve dhesions between the gl ns tub l surgery, nd tub l lig tion.
nd oreskin in uncircu cised les?
A) Adhesions re lw ys bnor l. You decide that this patient may have an ectopic pregnancy.
B) Age 6 onths. A urine HCG test is positive or pregnancy.
C) Age 1 ye r.
D) Age 2 ye rs. Question 1.19.3 The signi cance o a positive pregnancy
E) Age 3 ye rs. test is that:
A) An ultr sound will be ble to detect n ecto ic regn ncy i
The correct answer is “E.” So e dhesions re nor l in young one is resent.
children. However, the oreskin should be ully retr ct ble in B) T e seru level o HCG is at least 1,000 IU/ L.

C) Co bined with the tient’s bdo in l in nd cervic l Objectives: Did you learn to . . .
otion tenderness, it e ectively rules in n ecto ic regn ncy. • Evaluate a ertile emale with pelvic pain?
D) T e urine HCG is 98% sensitive or regn ncy 7 d ys er • Diagnose an ectopic pregnancy?
i l nt tion.

Answer 1.19.3 The correct answer is “D.” “A” is incorrect. T e QUICK QUIZ: TWISTED SISTER
regn ncy test is ositive very e rly nd ultr sound y not be
ositive by n ex erienced o er tor until 6 weeks o regn ncy. Which o the ollowing is ty ic l o ov ri n torsion?
“B” is incorrect. T e urine y be ositive t seru HCG lev- A) Periu bilic l in gr du lly igr ting to both the right nd
els o 25 to 50 IU/L. P tients y not h ve n HCG level o le qu dr nts.
1,000 IU/L until 6 weeks o regn ncy. “C” is incorrect bec use B) Sudden onset o colicky bdo in l in with v gin l bleed-
tients with nor l regn ncy y lso h ve bdo in l ing.
in nd cervic l otion tenderness. C) Sudden onset o colicky bdo in l in in one o the lower
qu dr nts.
T e patient’s serum HCG is 440 IU/L. You order an ultra- D) Sudden low b ck in with r di tion to the erineu .
sound and nd no evidence o an intrauterine or ectopic
pregnancy. The correct answer is “C.” P tients with ov ri n torsion resent
with sudden onset o severe lower bdo in l in. T e in is
Question 1.19.4 Your next step is to: requently colicky. Since only one ov ry is involved, the in
A) Re ssure the tient th t she does not h ve n ecto ic reg- is loc ted in one side or the other. S ont neous torsion/detor-
n ncy. sion y lso occur so th t the in y re it s ont neously.
B) Recheck the HCG in 48 hours. Ov ri n torsion c n be di gnosed by Do ler ultr sound th t
C) Re er or l rosco y to rule out ecto ic regn ncy. ex ines ow to the ov ries. M ny gynecologists consider this
D) Recheck n HCG in 1 to 2 weeks. clinic l di gnosis, so obt in consult tion e rly or sus ected
E) Follow the tient clinic lly. ov ri n torsion c ses.

Answer 1.19.4 The correct answer is “B.” T e HCG should CASE 1.20
double in nor l regn ncy every 1.8 to 3 d ys. I the HCG is
not doubling in this ti e r e, it is likely n ecto ic regn ncy. A middle-aged unresponsive, disheveled patient is brought
Re e ber, the ct th t you did not see n ecto ic regn ncy by emergency medical services (EMS) to your ED. T ey had
on ultr sound is irrelev nt. T e seru HCG is gener lly at least been called by his girl riend who had seen him lying in the
1,500 IU/L be ore nything is seen on ultr sound. By n HCG o grass outside his home this morning. He has spontaneous
6,500 IU/L, n ex erienced ultr sonogr her should cert inly respirations and has shallow respirations o 20 per minute
be ble to see regn ncy on ultr sound; i not seen, n ecto ic and a weak but palpable pulse at 110 beats per minute.
should be reconsidered. “A” is incorrect bec use o the bove.
“C” is incorrect. T is is inv sive nd not needed. “D” is incorrect Question 1.20.1 What should be your rst steps in assess
bec use o the ti e r e; the HCG should be rechecked in 24 ment and treatment?
to 48 hours. An ecto ic y well ru ture within 1 to 2 weeks. A) Oxygen by nonrebre ther sk (NRB), st t seru glucose,
“E” is incorrect. I you ollow the tient clinic lly, you re b si- n loxone, nd thi ine.
c lly s ying th t you will w it until the ecto ic ru tures be ore B) Oxygen by NRB, ECG, he d C .
ddressing the roble . C) Oxygen by NRB, intub te, ECG, he d C .
D) Intub te, ECG, he d C .
Question 1.19.5 You re check the HCG in 48 hours and it is
now 1,000 IU/L (prior level 440 IU/L). Your interpretation is Answer 1.20.1 The correct answer is “A.” T ere re sever l
that: c uses o unres onsiveness th t c n be i edi tely corrected.
A) T is tient does not likely h ve n ecto ic regn ncy. A hel ul lgorith to rec ll in the initi l tre t ent or n unre-
B) T is tient h s ol r regn ncy. s onsive tient is “DON’ ”: Dextrose, Oxygen, N loxone,
C) T is tient h s blighted ovu . hi ine (the so-c lled “co cockt il”). Answer “A” is correct
D) T e tient h s et l de ise o n intr uterine regn ncy. bec use n loxone nd oxygen re d inistered nd glucose is
E) All o the bove re ossible. checked. I r id blood sug r is un v il ble, e iric l d in-
istr tion o dextrose would be ro ri te. R id tre t ent
Answer 1.19.5 The correct answer is “A.” Since the HCG dou- o hy oxi , hy oglyce i , nd n rcotic overdose c n i rove
bled s ex ected in nor l regn ncy, it is not likely th t this ent l st tus nd thus void intub tion. ECG nd he d C y
is n ecto ic regn ncy, blighted ovu (“C”) or intr uterine be indic ted l ter in the ev lu tion. You could rgue or intub -
et l de ise (“D”). In ll o these conditions, the HCG would tion in this tient since he is unres onsive (“C” nd “D”) but
not double. “B” is lso not likely bec use in ol r regn ncy, the next ste s would not be ECG nd he d C . So “A” is the ost
the HCG would rise dr tic lly correct nswer.

incorrect; the tient still h s GCS o less th n 8 nd is un ble

T e patient is ound to be hypothermic, hypoglycemic, and to rotect his irw y so he should not be extub ted.
hypoxic. He is placed on oxygen and given warm normal saline,
an amp o D50W, and naloxone. T e patient now is saturating Objectives: Did you learn to . . .
at 98%on NRB. He is responding to pain ul stimuli by moan- • Rapidly assess and treat an unresponsive patient?
ing and withdrawing his extremities but is not opening his • Use the GCS to determine need or intubation?
eyes. He has gurgling respirations and still has no gag ref ex.

Question 1.20.2 What is your next step? CASE 1.21

A) Intub te. You are working in a rural ED and get a call that the volun-
B) Obt in he d C . teer ambulance service is bringing an unresponsive, adult
C) Obt in ECG. male patient status post motor vehicle collision. T ey bring
D) Continue on NRB. the patient on a backboard with a c-collar.
E) Obt in n ABG.
Question 1.21.1 The primary survey o a trauma patient
Answer 1.20.2 The correct answer is “A.” Although the tient includes all o the ollowing EXCEPT:
h s i roved nd h s nor l oxygen s tur tion, his level o A) Check or ulses.
consciousness is still too low to rotect his irw y. T us, he B) I obilize the c-s ine, ev lu te the irw y, nd listen or
should be intub ted be ore urther di gnostic studies re er- bre th sounds.
or ed. A si le ethod to deter ine the need or intub tion C) GCS.
is the GCS ( ble 1-5). P tients with GCS o 8 or less should be D) Abdo in l ex in tion.
intub ted, s they c nnot rotect their irw y ro s ir tion o E) Unclothe the tient.
or l secretions nd/or e esis. T e rhy e “GCS o 8, intub te”
ssists in recollection o this rule. T is tient h s GCS o 7 Answer 1.21.1 The correct answer (and what you do
(eyes 1, verb l 2, ove ent 4). He h s gurgling res ir tions, not want to do in the primary survey) is “D.” T e ri ry
nd you c nnot ensure he is ble to rotect his irw y. T ere- survey is the initi l ev lu tion er or ed on every tr u
ore he should be intub ted be ore other studies or interven- tient by the lgorith “ABCDE.” A: Airw y ssess ent
tions. “D” is incorrect bec use he c nnot rotect his irw y. “E” includes c-s ine i obiliz tion; o ening the irw y by j w
is incorrect because the decision to intubate is a clinical one thrust/chin li ; nd, when indic ted, b g-v lve sk, intub -
and not tied directly to the blood gas! tion, or cricothyroto y. B: Bre thing includes listening or
bre th sounds, d inistering oxygen, nd tre ting neu o-
T e girl riend arrives and gives urther history that the thor ces. C: Circul tion requires ssess ent o BP, checking
patient is an alcoholic and had told her he had quit drinking ulses nd tre t ent o hy otension nd t chyc rdi with
2 days ago. She states he has had a seizure in the past when he cryst lloids nd blood. D: Dis bility is the r id neurologic
stops drinking. He starts to seize be ore your eyes. ex in tion or otenti l cord injury nd GCS. E: Ex osure
involves disrobing the tient nd rolling the to ssess ny
Question 1.20.3 What should you do now? injury to the b ck.
A) Give lor ze nd d it or rob ble deliriu tre ens
(D s). On the primary survey, the patient was not protecting his
B) Give lor ze , obt in he d C , blood cultures, nd ECG. airway and was intubated with an 8-mm endotracheal tube
C) Give lor ze , extub te, nd d it or rob ble D s. (E ) with rapid sequence intubation (RSI). T e patient
D) Give henytoin nd d it or rob ble D s. is noted to have breath sounds on the right but no breath
sounds on the le .
Answer 1.20.3 The correct answer is “B,” give lorazepam to
abort the seizure. Even though it is e sy to ssu e th t the Question 1.21.2 What is the next best step in evaluation
tient h d seizure ro D s, which y h ve resulted in and treatment o this patient?
hy oxi , hy other i , nd hy oglyce i , this kind o think- A) Re ove the E ; you ust be in the eso h gus.
ing c n le d to errors. It is still ossible th t the tient h s B) Get chest x-r y to con r tube l ce ent.
s ont neous or tr u tic br in he orrh ge, thus the need or C) Do needle deco ression o le chest.
he d C . It is lso ossible th t the tient is se tic; re e - D) Insert le chest tube.
ber th t hy other i c n be seen with se sis. T us, blood cul- E) Check E or de th t the teeth nd osition.
tures should be obt ined nd ossibly n LP er or ed. Fin lly,
n ECG c n show yoc rdi l in rction or rrhyth i th t Answer 1.21.2 The correct answer is “E.” T is tient h s
y lso result in seizure. “D” is incorrect bec use henytoin bre th sounds on the right; there ore, eso h ge l intub tion is
is not the drug o choice or n ctively seizing tient; ben- unlikely, king “A” incorrect. T e ost likely nd e sily rec-
zodi ze ine such s lor ze should be d inistered. And, ogniz ble source o bsent bre th sounds on the le is right
henytoin does not work in lcohol withdr w l seizures. “C” is in ste bronchus intub tion. T us, looking t the de th o

l ce ent o the E t the teeth (“E”) is the initi l ev lu tion

indic ted. T e E should be l ced t bout three ti es the T e patient now has a chest tube in place but remains hypo-
size o the E (i.e., 3 × 8 = 24 c ) ssu ing th t the size o tensive. wo large bore (18 gauge or larger) IVs were estab-
E w s correctly chosen. T is is n i ort nt c lcul tion to lished. No external source o bleeding is identi ed.
re e ber, s it lso lies to edi tric tients. A chest x-r y
c n lso ev lu te or right in ste intub tion but should not Question 1.21.5 When should blood be administered?
be the rst ste . A neu othor x y be the c use o unil ter l A) I edi tely.
bre th sounds, but right, or less co only, le , in ste intu- B) I tient is hy otensive.
b tion should be considered rst. C) I ersistent hy otension er 1 L o nor l s line.
D) I ersistent hy otension er 4 L o nor l s line.
Question 1.21.3 You now note that there is an open chest E) I FAS ex in tion shows intr bdo in l ree uid.
wound to the le t lateral rib cage. Funny . . . you didn’t
notice that be ore. What is the initial treatment o this new Answer 1.21.5 The correct answer is “C.” I tient rrives
nding? hy otensive with no signs o extern l bleeding, 1 L o cryst lloid
A) Needle thor costo y. (nor l s line) should be given i edi tely. T e tr dition l
B) Chest tube l ce ent. te ching h s been to st rt blood er hy otension unres onsive
C) Occlusive dressing. to 2 liters o s line. T is h s ch nged in the ost recent A LS
D) Chest x-r y. guidelines; we don’t know which will be the correct nswer
on the test. I the tient continues to be hy otensive, cked
Answer 1.21.3 The correct answer is “C.” T is tient h s n red blood cells should be st rted long with ddition l nor l
o en “sucking” chest wound. E ch ti e the tient ins ires, ir s line. T e FAS ex in tion is r id bedside ultr sound to
c n be sucked into the chest c vity cting s one-w y v lve. identi y ree uid in the tr u tient’s bdo en nd eric r-
T is c n result in tension neu othor x. T us, the initi l di l s c. Persistent hy otension with ositive FAS ex in tion
tre t ent is to ly n occlusive dressing to the wound (e.g., is n indic tion or e ergent ex lor tory l roto y.
such s etrol tu g uze). Objectives: Did you learn to . . .
• Employ the primary assessment o a trauma patient?
Following the placement o the occlusive dressing the patient • Treat an open chest wound?
continues to have absence o breath sounds on the le , is now • Resuscitate an unstable trauma patient?
hypotensive, and has distended neck veins. T e presumed
diagnosis is a tension pneumothorax.
Question 1.21.4 What should you do now? Tranexamic acid can be used as a hemostatic agent in
A) Chest x-r y. hypotensive trauma patients. I you are going to trans-
B) Chest tube l ce ent through wound. use a large amount o blood the best evidence sug-
C) Chest tube l ce ent through se r te site. gests blood:FFP:platelets in a 1:1:1 ratio.
D) Re ove occlusive dressing.

Answer 1.21.4 The correct answer is “D.” T e occlusive dress- QUICK QUIZ: CHEST PAIN
ing itsel y c use tension neu othor x, so its l ce ent
should be i edi tely ollowed by chest tube l ce ent. I A 54-ye r-old e le resents to your ED with chie co l int o
tension neu othor x develo s be ore the tube is l ced, chest in. She st tes it c e on suddenly while she w s trying to rid
re oving the dressing (“D”) c n usu lly llevi te the tension her g rden o l gue o thistles (or g rlic ust rd–your choice).
co onent. E ergency edic l technici ns will o en l ce She describes it s “sh r ” nd it r di tes through to her b ck. She
dressing th t is closed only on three sides to serve s rele se re orts di culty bre thing. Her st edic l history is ertinent or
v lve nd void this ossibility. T e di gnosis o tension neu- hy ertension, bre st c ncer, nd obesity. She is s oker.
othor x is clinic l. T e ti e required to obt in chest x-r y B sed on this history, wh t di gnosis c n be excluded ro
y result in the de th o the tient. When l cing chest tube your di erenti l?
in tient with n o en wound, never pass the tube through A) Acute yoc rdi l in rction.
the wound, s it is likely to ollow the th o the initi l enetr - B) Aortic dissection.
tion into lung renchy . C) Pul on ry e bolis .
D) Pneu othor x.
E) None o the bove.
Needle thoracostomy is also use ul in a tension The correct answer is “E.” T e tient’s history is ost sugges-
pneumothorax and should be the initial step in most tive o ul on ry e bolis with her co l int o sh r chest
cases. in, trouble bre thing, c ncer history, nd s oking. However,
t this oint in ti e, ll o the etiologies listed— nd ore—

ust be considered. Wo en o en h ve ty ic l resent tions Answer 1.22.1 The correct answer is “C.” M ny children who
o c rdi c chest in. In ddition, tients o en use the ter re vo iting nd h ve di rrhe will be ble to toler te s ll
“sh r ” to describe “intense” or “strong” in. (5 cc) si s o uid d inistered every ew inutes. Or l u-
ids should be tte ted rior to IV ther y. One ight lso
d inister ond nsetron to hel reduce vo iting (2 g in those
QUICK QUIZ: AORTIC DISSECTION <15 kg, 4 g in those >15 kg). In children who re severely
dehydr ted, s evidenced by ltered ent l st tus or ch nge in
In ortic dissection, the BP is di erent between the extre ities skin turgor, IV uid resuscit tion should begin i edi tely. I
in less th n 30% o c ses. I you diagnose thoracic aortic dis- IV rehydr tion is considered ro ri te, use nor l s line in
section, and the patient’s BP is di erent in the upper extremi- 20 cc/kg liquots. T ere ore, nswers “A” nd “B” re not cor-
ties, what limb should you use to guide BP management? rect. Pro eth zine (“D”) is n ntie etic th t h s been used
A) Right r . in children in the st. However, ro eth zine h s received
B) Le r . “bl ck box” w rning ro the FDA or children younger th n
C) Either lower extre ity. 2 ye rs, s there is risk o res ir tory de ression.
D) T e li b with the highest BP.
E) T e li b with the lowest BP. You obtain some lab work and notice that the child has nor-
mal renal unction but low serum bicarbonate, indicating a
The correct answer is “D.” An ortic dissection yi ir the possible metabolic acidosis. In speaking with his mother, you
blood ow to cert in extre ities due to the lse lu en. T e discover that earlier in the day, he was playing unsupervised
BP should be int ined t systolic BP o 100 to 120 Hg in the bathroom, where she keeps her prenatal vitamin. Upon
(or bit lower) in the extre ity with the highest BP. T is will questioning the child, he states that he ate a bunch o “candy”
decre se the orces ro g ting the dissection. in the bathroom about 3 hours ago (all the more reason to
keep things up high and away rom children!).
Patients with an aortic dissection should be started Question 1.22.2 What component o prenatal vitamins is
on a beta-blocker (e.g., esmolol) and vasodilator drip most concerning or toxicity?
(nitroglycerin, nitroprusside) to control BP and mini- A) Folic cid.
mize stress to the aortic wall. The goal is a pulse o B) Iron.
approximately 60 bpm and a blood pressure o 100 C) C lciu .
to 120 mm Hg systolic. Remember that lowering the D) Vit in D.
pulse rate is just as important as reducing the blood
pressure. Answer 1.22.2 The correct answer is “B.” Folic cid, c lciu ,
nd vit in D re ll toler ted well in high doses, s their
bsor tion ro the GI tr ct is li ited. Iron, however, c n con-
tinue to be bsorbed while it re ins in the GI tr ct. Iron is
CASE 1.22 direct irrit nt to the GI ucos (there ore, the bloody e esis
nd di rrhe ) nd inter eres with the electron tr ns ort ch in
A mother brings her 3-year-old child into the ED. She states nd erobic et bolis .
that the child has been vomiting and complaining o abdom-
inal pain all a ernoon. He has had between 8 and 10 epi- Question 1.22.3 The nurse asks i you should add on an iron
sodes o emesis; the last two have contained small amounts level to the blood that was drawn 3 hours a ter the inges
o bright red blood. He has had a little nonbloody diarrhea. tion. You respond:
He has not been tolerating f uids. On examination, you A) “No th nks. Iron levels re not hel ul.”
nd the child to be moderately ill appearing with normal B) “No th nks. It’s too e rly. We need to w it until t le st
color, but he seems less interactive than you would expect. 12 hours h ve el sed.”
His vitals reveal a temperature o 36.5 degrees C, a pulse C) “Yes, le se. I it’s nor l, we don’t need ny urther tre t ent.”
o 170 bpm, a respiratory rate o 28, and a BP o 98/58 mm D) “Yes, le se. It y hel us deter ine the severity o toxicity.”
Hg. His abdomen is slightly and di usely tender. He has dry
mucous membranes. Answer 1.22.3 The correct answer is “D.” T e iron level
between 2 nd 4 hours er ingestion is the ost ccur te;
Question 1.22.1 In general (not speci cally in this patient) beyond this eriod, the jority o the iron is oving intr cel-
what is the initial treatment o a moderately dehydrated lul rly nd c nnot be e sured. For slow-rele se iron, seru
child? concentr tions should be e sured t 6 to 8 hours er inges-
A) 20 cc/kg bolus o D5 1/2 NS. tion. T ese e sures will give you e k seru iron concentr -
B) 10 cc/kg bolus o isotonic cryst lloid uid. tion th t correl tes well with the severity o toxicity. However, a
C) Or l ch llenge o s ll ount o electrolyte solution. low serum level o iron does not mean the symptomatic patient is
D) 12.5 g ro eth zine su ository. OK. Treatment is based on clinical ndings and NOT on serum

iron levels. Once the iron oves into the eri hery, the seru TABLE 1-7 MANIFESTATIONS OF IRON TOXICITY
levels c n be low des ite signi c nt toxicity.
First (or early) Hours 0–6 Vomiting and diarrhea, o ten
phase (rarely > 6 bloody
Question 1.22.4 How do patients with an iron overdose hours) Metabolic acidosis
A) Abdo in l in, vo iting, nd di rrhe .
B) He te esis, shock, nd co . Second (or 3–48 hours Resolving acidosis
C) Rel tively sy to tic. quiescent) (time variable) Resolving hypovolemia
D) All o the bove. Frequently, asymptomatic

Third phase 12–48 hours GI hemorrhage

Answer 1.22.4 The correct answer is “D.” P tients who h ve (time variable) Lethargy, coma, shock
h d n iron overdose cl ssic lly ss through ive di erent
Cardiovascular collapse
h ses. he irst h se is ch r cterized by n use , vo iting,
Metabolic acidosis
di rrhe , nd bdo in l in. here y be he te esis
Renal ailure (variable)
nd he tochezi s the GI ucos beco es irrit ted. he
second h se is rel tively sy to tic eriod s the GI Fourth phase 2 days or Hepatotoxicity
sy to s resolve. During this quiet h se, iron is bsorbed more Hepatic necrosis
nd tr ns orted to the eri hery where it c uses the inter- Coma
ru tion o erobic et bolis . In the next (third) h se,
Fi th phase 2–4 weeks GI obstruction due to strictures
tients beco e hy otensive, cidotic, nd c n develo and scarring
ultisyste org n ilure nd co . It is this shock th t is
the usu l c use o de th in iron toxicity. he ourth h se
is her lded by he tic necrosis. Liver ilure, which does
not occur in ll tients, is the second ost requent c use HELPFUL TIP:
o de th in c ses o iron toxicity. Fin lly, the tient y Patients who are entirely asymptomatic 6 hours a ter
develo bowel obstructions 2 to 4 weeks or longer ter the iron ingestion and do not have any radiographic evi-
ingestion due to stricture or tion t the site o ucos l dence o iron in the GI tract are not at risk or toxicity.
irrit tion. See ble 1-7. They can be sa ely discharged with close ollow-up.
The caveat is that chewable multivitamins are not radi-
Question 1.22.5 Abdominal lms reveal radiopaque pills opaque and will not show up on x-ray.
in the stomach. What is the best next step in treatment or
this patient?
A) Whole bowel irrig tion with olyethylene glycol solution.
B) G stric l v ge. Question 1.22.6 The patient is symptomatic (vomiting and
C) Activ ted ch rco l. diarrhea), acidotic, and also has an iron level 650 µg/dL,
D) Syru o i ec c. which puts him at signi cant risk or toxicity. What is your
next step?
Answer 1.22.5 The correct answer is “A.” G stric l v ge nd A) Correction o cid–b se disturb nce nd ggressive uid
vo iting induced by syru o i ec c both ent il ir ount resuscit tion.
o risk nd neither h s been shown to be bene ci l. In ddi- B) ED A.
tion, there is the risk o s ir tion nd subsequent neu oni- C) De erox ine.
tis. T ere ore, “B” nd “D” re not correct. Iron, lithiu , nd D) A nd B.
le d will not dsorb to ctiv ted ch rco l; there ore, it is o E) A nd C.
no bene t in such c ses, nd “C” is incorrect. re t ent or
iron toxicity involves whole bowel irrig tion with olyethyl- Answer 1.22.6 The correct answer is “E.” In ddition to sy -
ene glycol solution to ush the iron out o the GI tr ct. T ere to s nd cidosis, n iron level >500 µg/dL or ingestion o
re v rious doses nd r tes o d inistr tion ublished, but ore th n 60 g/kg o ele ent l iron re considered high-risk
10 to 15 L/kg/hr, u to 2,000 cc/hr, see s to be re son ble situ tions, nd chel tion with de erox ine is w rr nted. De -
l ce to st rt. T is requires the l ce ent o n sog stric erox ine is used to chel te iron, while ED A is chel tion
tube. I tient does not toler te the volu e o the in usion, tre t ent or le d oisoning. F stidious su ortive c re, with
the r te should be decre sed by 50%. T e irrig tion should correction o the tient’s volu e nd cid–b se disturb nces,
continue until the rect l ef uent is cle r nd there re no is i er tive. Ensuring th t the tient is euvole ic is es e-
visible ill r g ents. I ollow-u r diogr hs de onstr te ci lly i ort nt when using chel tion ther y, given th t the
ersistent iron t blets in the sto ch, consider the ossibility jor side e ect o de erox ine is hy otension. T e dose o
o bezo r h ving or ed, which y require endosco ic or de erox ine is 15 g/kg/hr or 24 hours, but y be slowed
surgic l intervention or re ov l. down i the tient beco es hy otensive.

colonizes the genit l tr ct o nor l he lthy wo en. GBS y

be the ost co on c use o b cteri l in ection in the newborn.
Dialysis does not remove iron rom the blood stream
T e e k incidence o GBS dise se is in the rst 7 d ys o li e, but
nor the intracellular space, where the majority o it will
there y be del yed resent tion out to 30 d ys. Pseudomonas
be ound. Dialysis may be indicated to treat renal ailure
in ections re not co only seen in the neon t l eriod.
or persistent pro ound acidosis.

HELPFUL TIP: Look care ully or cold sores or other vesicular lesions on
The much touted “de eroxamine challenge” to see i children with rashes. Also try to get a history o any close
there is ree iron in the blood is not an accurate predic- contacts between the patient and people with cold sores.
tor o toxicity. The test is done by giving an individual a Herpes virus in ection can be devastating to the newborn,
single challenge dose o de eroxamine and seeing i the and they may require treatment with antiviral medication.
urine changes to a “vin rose” color re lecting circulat-
ing ree iron. However, this does not predict who needs
therapy, since the iron may already be working its evil T e child is seen in her ather’s arms. She appears to have
in the periphery. normal color and tone. She is sleeping, but arouses a er some
stimulation. She seems ussy, but can be consoled by her par-
ents. Vitals: temperature 38.7°C rectally, pulse 165 bpm, and
Objectives: Did you learn to . . . respiratory rate 32. She appears to be well hydrated, and oth-
• Rehydrate a child with GI symptoms? erwise has a completely normal physical examination.
• Recognize the mani estations o iron poisoning?
• Manage a child with an iron ingestion? Question 1.23.2 What urther evaluation is indicated now?
A) CBC, blood cultures, c theterized urine or n lysis nd culture.
B) CBC, blood cultures, b g urine or n lysis nd culture.
C) CBC, blood cultures, chest r diogr h, c theterized urine
CASE 1.23 or n lysis nd culture.
A 25-day-old emale newborn is brought to the ED by her D) CBC, blood cultures, c theterized urine or n lysis nd cul-
parents. T ey state that she has not been breast- eeding well ture, lu b r uncture, nd chest r diogr h.
this morning and has elt warm. T ey measured her axillary
temperature as 100.6°F with an axillary digital thermom- Answer 1.23.2 The correct answer is “D.” It is i ort nt th t
eter at home. T ey have not noticed any rhinorrhea, cough, co lete ev lu tion nd se tic work-u be er or ed on ll
or rashes. T e baby is having ve to six wet diapers per day children younger th n 28 d ys old without de nite source o
and ve to six yellow seedy stools per day. T e child has not in ection. T is includes CBC, blood cultures, c theterized urine
had any sick contacts. She slept normally last night, but was a s eci ens or n lysis nd culture, nd lu b r uncture. A
little hard to wake up rom her morning nap today. T e baby chest x-r y need not be done in the tient without res ir tory
was the 7 lb 8 oz product o an uncomplicated term gestation, sy to s but is highly reco ended. LP is nd tory. Even i
born via normal spontaneous vaginal delivery to a group B you sus ect neu oni or U I, n LP should still be consid-
streptococcus (GBS)-negative mother. T ere were no compli- ered, s it is i ossible to tell i the b cteri h ve s re d he -
cations in the early neonatal period, and the baby was dis- togenously to the eninge l s ce.
charged with the mother at 2 days o li e a er receiving rou-
tine neonatal care. At her 2-week weight check, she seemed to
be gaining weight well and her doctor had no concerns.
Do not delay antibiotic therapy to obtain a lumbar punc-
ture. Lumbar punctures per ormed within 2 to 4 hours
Question 1.23.1 Which o these is NOT a common cause o
o receiving antibiotics should still yield valid results.
serious in ections in children younger than 1 month?
A) Listeria monocytogenes.
B) Neisseria meningitides. HELPFUL AND CONTROVERSIAL TIP:
C) GBS. Some would argue that a bag urine should be done as
D) Pseudomonas aeruginosa. the initial urine examination. While not as speci ic as
a catheterized urine, it is more sensitive or UTI. I the
Answer 1.23.1 The correct answer is “D.” “A,” L. monocyto- bag UA comes back positive, a catheterized specimen
genes, is n oblig te intr cellul r n erobe th t is tr ns itted should be sent or culture.
tr ns l cent lly ro other to child. “B,” N. meningitides, is
Gr -neg tive di lococcus th t colonizes the res ir tory
tr ct o u to 15% o he lthy individu ls. It is usu lly s re d Question 1.23.3 You are awaiting lab results. Should you
through close cont ct. “C,” GBS, is Gr - ositive org nis th t play World o Warcra t, Minecra t or start antibiotics? You

decide to start antibiotics. Which antibiotics are most on gener l edi trics oor inste d o n intensive c re unit.
appropriate or empiric therapy in this patient? T is child should be d itted, reg rdless o wh t the l bor -
A) A icillin nd gent icin. tory results de onstr te. So e ex erienced r ctitioners will
B) Ce ri xone. disch rge nontoxic ebrile child ro the ED i he or she is
C) V l cyclovir. older th n 2 onths nd h s ollow-u within 24 hours. How-
D) A oxicillin with or without cl vul n te. ever, there is so e risk inherent in this r ctice—n ely, th t
E) Any o the bove re equ lly v lid choices. deterior tion in the tient’s condition y go unrecognized t
ho e nd th t the ily will il to ollow-u . T e st nd rd o
Answer 1.23.3 The correct answer is “A.” A icillin nd gen- c re is to d it ll children who h ve ever when they re less
t icin cover ll o the co on c uses o serious b cteri l th n 30 d ys old.
in ection in the newborn, nd both ntibiotics enetr te into
the cerebros in l uid (CSF) well. Ce ri xone lso enetr tes HELPFUL TIP:
the CSF well, but is highly bound to lbu in nd y dis l ce With the advent o the polyvalent pneumococcal vac-
bilirubin. T ere h ve been c se re orts o kernicterus ollow- cine and the implementation o universal screening or
ing the d inistr tion o ce ri xone in newborns, so its use is GBS, the incidence o occult serious bacterial in ection is
not reco ended in children younger th n 1 onth. I there alling. It may be that in the near uture, the way in which
is concern or her es virus in ection, cyclovir IV would be ebrile in ants younger than 3 months are evaluated and
re erred over v l cyclovir, but neither o these is used on n treated will change. However, the practice outlined in
e iric b sis routinely. A oxicillin, with or without cl vul - Table 1-8 represents the current standard o care.
n te, does not enetr te the CSF s well s icillin nd is
thus not re erred when eningitis is ossibility. HELPFUL TIP:
Even when present, otitis media is not considered
Question 1.23.4 What is the appropriate disposition or this a source o ever when evaluating the neonate. You
child? should continue with your clinical and laboratory evalu-
A) Ad ission to the gener l edi trics oor. ation as i you did not even see the ears!
B) Ad ission to the edi tric intensive c re unit.
C) Monitor or 3 hours in the ED, nd decide b sed on l bor -
tory results. Objectives: Did you learn to . . .
D) Disch rge with 24-hour ollow-u . • Describe common bacterial agents causing in ection in the
early neonatal period?
Answer 1.23.4 The correct answer is “A.” T is child does • Evaluate the ebrile newborn?
not look toxic nd c n rob bly be n ged ro ri tely • Manage the ebrile newborn?


Age ≤ 28 days
• These neonates are assumed to have bacteremia and potential seeding o the CSF, even i a source is discovered.
• Work-up should include cultures o blood, urine, CSF, and stool (i GI symptoms present) and CXR (i respiratory symptoms present).
• CBC and/or CRP can be obtained, but the decision about whether or not to proceed with evaluation should not be based on these results!
• The child should be admitted or IV antibiotics until cultures are negative.

Age 1–3 months

• It is sa est to assume they are still unable to contain bacterial in ections at this age.
• Patients at low risk o having a serious bacterial in ection have the ollowing labs:
• WBC >5,000, <15,000/mm 3 with band count <1,500/mm 3
• Normal urinalysis
• Normal CSF
• Stool microscopy <5 WBC/HPF i diarrhea present
• I no source is ound on examination, it is reasonable or patients meeting these low-risk criteria to be managed with intramuscular ce triaxone in the
ED/clinic—i ollow-up can be arranged to receive a second dose in 24 hours.
• It should be emphasized that these in ants are still vulnerable to dissemination o bacterial in ections. There ore, those with an obvious source, those
who appear clinically ill, or those who do not meet the low-risk criteria should be cultured and admitted or IV antibiotics until cultures are negative.

Age 3–36 months

• Management o ever in this group is somewhat controversial, as the advent o Prevnar (pneumococcal vaccine) and continued use o HIB vaccine will
presumably reduce the risk o invasive bacterial disease.
• It is generally accepted that well-appearing children with evers less than 39°C do not require urther evaluation or antibiotics.
• Up to 5% o children with temperature >39°C who appear clinically well will have positive blood cultures (occult bacteremia), putting them at risk or
serious in ections. One approach is to obtain screening WBC on those with evers >39°C. I WBC <5,000 or >15,000/mm 3 or bands >l,500/mm 3, then
urther evaluation o blood, urine, and CSF should be considered.

however, children y require control o the irw y due to

CASE 1.24 hy oxi . “A,” neu oni , is n in ection o the lower irw ys th t
A 6-month-old male is brought to the ED by his ather. He c n be either b cteri l or vir l in n ture. T ese children gener lly
has had a little bit o rhinorrhea or the last 36 hours but no h ve ever nd roductive cough. T ey y be t chy neic nd
evers. A ew hours ago, he began coughing and seemed to h ve n incre sed work o bre thing, but they usu lly do not h ve
be having some di culty breathing. He has been taking his ins ir tory stridor. “C,” l ryngo l ci , is congenit l disorder.
bottle and rice cereal well. His ather states that there have T ese children usu lly develo sy to s t ew weeks o ge
been no changes in his stools. He is ully vaccinated, has no nd resent with ins ir tory stridor th t gets worse with crying. It
signi cant past medical history, and has had no known sick tends to be little better when the child is c l nd in the su ine
contacts. osition. L ryngo l ci resolves s ont neously in the jor-
ity o children s the l rynx beco es ore r nd the irw y
Question 1.24.1 What is the most common cause o respi di eter incre ses, but so e children will require surgic l inter-
ratory distress in a 6 month old (and not necessarily the vention to cilit te eeding nd growth. T e child in this vignette
diagnosis in this child)? is resenting with new roble , s o osed to chronic one, so
A) Pneu oni . this is not l ryngo l ci . “D,” sth , is nother dise se o the
B) Foreign body s ir tion. lower irw ys, nd wheezing is ex ir tory in n ture.
C) Bronchiolitis.
D) Second-h nd s oke ex osure. You decide to do a radiograph o this child’s neck to aid in the
diagnosis (although this is certainly not necessary nor advo-
Answer 1.24.1 The correct answer is “C.” Bronchiolitis is very cated in most cases—but this is a board review book, not real
co on, es eci lly in the winter onths. It is usu lly c used li e).
by the res ir tory syncyti l virus, but c n lso be c used by
r in uenz , in uenz , nd hu n et neu ovirus. Bron- Question 1.24.3 You are most likely to see which o the
chiolitis is usu lly ssoci ted with ro use rhinorrhe , broncho- ollowing on cervical radiograph?
s s , nd ucus lugging o the bronchiole tree. Although, A) T u b sign.
“A,” neu oni is serious c use o res ir tory roble s, it is B) Quincke sign
not terribly co on in in nts. “B,” oreign body s ir tion, is C) S ine sign.
so ething th t ust be lw ys considered in n in nt, es e- D) Retro h rynge l s ce swelling.
ci lly 6- onth-old who is beco ing ore obile ( nd to E) Stee le sign.
who everything looks like ood). Second-h nd s oke ex o-
sure c n c use chronic irrit tion to the res ir tory tr ct nd c n Answer 1.24.3 The correct answer is “E.” R diogr hs in
ex cerb te bronchos s , but it is in requently the sole c use o crou show the “stee le sign,” which is subglottic n rrowing
res ir tory distress. o the tr che ro ede , giving it stee le-like e r nce.
“A,” the thu b sign, is seen in e iglottitis. “B,” Quincke sign is
As you examine the child, you note that he is mildly tachy- incorrect, s it h s nothing to do with r diology. Quincke sign
pneic with some suprasternal, subcostal, and intercos- is the ungu l c ill ry uls tion ssoci ted with ortic insu -
tal retractions. He makes a whistling, wheezing sound on ciency—it’s r re, not seen in children, nd ne rly useless knowl-
inspiration (stridor) that seems to get worse the harder he edge . . . but th t is wh t you re ying us or! “C,” the s ine
breathes. He also has a brassy-sounding cough that does not sign, is loss o rogressive r diolucency o the s ine on l ter l
seem to be productive. chest r diogr h. T is is seen when so ething—cl ssic lly
n in ltr te indic tive o neu oni —is overl ying the lower
Question 1.24.2 What is the most likely diagnosis at this thor cic s ine king the vertebr l bodies e r ore dense.
point? Fin lly, “D,” retro h rynge l s ce swelling, is seen in retro h -
A) Pneu oni . rynge l bscess.
B) Crou .
C) L ryngo l ci . Question 1.24.4 What is the most appropriate de nitive
D) Asth . therapy or this patient at this time?
A) E ine hrine 0.01 g SQ.
Answer 1.24.2 The correct answer is “B.” Crou , or l ryngotr - B) Nebulized lbuterol.
cheobronchitis, is co on in ection o the u er nd lower C) Dex eth sone 0.6 g/kg PO/IM/IV.
res ir tory tr ct. It is ost co only c used by r in uenz D) High ow oxygen nd re re to intub te.
virus, but y lso be c used by in uenz nd res ir tory syn-
cyti l virus. Cl ssic lly, this ects children younger th n 5 Answer 1.24.4 The correct answer is “C.” Corticosteroids hel
ye rs, lthough it is occ sion lly seen in older children. As the to decre se the glottic ede . One dose o dex eth sone 0.3
glottis swells, children develo wheeze/whistle on ins ir tion to 0.6 g/kg ( xi u o 10 g) c n be given vi ulti le
(ins ir tory stridor) nd ch r cteristic br ssy “se l-like” b rk- routes (PO/IM/IV) nd is usu lly su cient to i rove the ir-
ing cough. T e v st jority o c ses re ild. Occ sion lly, w y swelling enough to llow the child to bre the co ort bly.

T e dv nt ge o dex eth sone over rednisone or nother

corticosteroid is th t its long h l -li e obvi tes the need or ur- QUICK QUIZ: FOREIGN BODY
ther dosing t ho e. While w iting or the dex eth sone to
work, e ine hrine y be d inistered vi nebulizer or severe A 3-ye r-old boy nd his 5-ye r-old sister were being silly,
c ses. T is usu lly le ds to signi c nt clinic l i rove ent nd voiding bedti e, nd ju ing on their rent’s bed. N tur lly,
gives ti e or the steroid to begin to t ke e ect. Subcut neous he h d nickel in his outh th t he’d ound on the oor. When
e ine hrine is usu lly unnecess ry. Albuterol, while hel ul or their other w lked in to wr ngle the into their j s, they
bronchos s , does not do nything to tre t the glottic ede redict bly collided in id- ir nd both ell o the bed nd onto
th t is c using the jority o the res ir tory distress. Intub - the oor. She w s un ble to nd the nickel er the incident.
tion is not indic ted t this oint i the child is not in i ending Coincident lly, the 3-ye r-old eels like he h s so ething stuck
res ir tory ilure, hy oxic, or ini lly res onsive. in his thro t—so ething with T o s Je erson’s he d on it.
When the ily rrives in your o ce, he t kes liquids
HELPFUL TIP: without uch trouble, but won’t t ke nything solid. He s ys
While classically we have used racemic epinephrine, the his “thro t hurts.” He’s not drooling or h ving ny trouble
“d” isomer is inactive. In addition, racemic epinephrine is bre thing.
more expensive and must be kept re rigerated i a multi-
dose vial is used. L-epinephrine, 5 cc o 1:1,000, delivered How do you con r th t the coin is not in the irw y?
by nebulizer is as—i not more—e ective, than racemic A) C o the l rynx nd chest without IV contr st.
epinephrine, is cheaper, and (our avorite since we can’t B) C o the l rynx nd chest with IV contr st.
do simple math!) is the same dose or everyone. C) AP nd l ter l l in l s o the neck.
D) Direct l ryngosco y.
E) C ll ul onologist or e ergent bero tic bronchosco y.
You administer the appropriate dose o dexamethasone to
the child along with a treatment o nebulized epinephrine. The correct answer is “C.” Fortun tely coins re r dio que—
He improves markedly. You watch him or 2 hours. He is able t le st s o the rinting o this book ( ybe we’ll h ve wood-
to tolerate oral f uids well, and is active and play ul. He still en coins g in so ed y!). So e l stic toys leg lly cont in
has a brassy cough, but no inspiratory stridor. b riu nd re r dio que while others re in dvertently
r dio que (like those de in Chin cont in ted with
Question 1.24.5 What should his disposition be? le d . . . ixed blessing t best!). T e eso h gus tends to col-
A) Ad it or 23 hours o observ tion. l se ro nterior to osterior when there is nothing in the
B) Ad inister second dose o r ce ic e ine hrine nd re- lu en. T ere ore, coin in the eso h gus should look round
ev lu te. on n AP x-r y. By contr st, the tr che is su orted by c rti-
C) Disch rge to ho e with close out tient ollow-u . l ginous rings round ost o its circu erence. T e osterior
D) Ad inister lbuterol nd re-ev lu te. rt o the tr che , however, buts the eso h gus nd h s no
c rtil ge. T ere ore, coins th t ll into the tr che gener lly
Answer 1.24.5 The correct answer is “C.” A er d inister- h ve n end-on e r nce on AP r diogr hs nd look like
ing dex eth sone nd e ine hrine, it is i er tive to observe disc on l ter l l .
children or t le st 2 hours. I child redevelo s stridor t rest,
he/she should receive second dose o e ine hrine. Any child T e coin ell into the stomach on the way to x-ray and the
who needs second tre t ent h s ore severe crou , is t little boy eels better.
higher risk o h ving co lic tions, nd should be considered
or hos it l d ission. I the child is ree o stridor 2 hours er Wh t oreign bodies in the stomach need to be re oved e er-
nebulized e ine hrine, she c n be s ely disch rged with close gently?
out tient ollow-u (within 24 hours) s long s the rents re A) A button b ttery.
reli ble, ble to onitor the child, co ort ble with the l n, B) A ercli th t is olded in its origin l or .
nd ble to return i the child’s condition should deterior te. C) wo s ll gnets.
D) A doll’s shoe.

Remember that an oxygen saturation o less than 95% is The correct answer is “C.” wo gnets c n ttr ct e ch other
singularly abnormal in a child. through o osing loo s o bowel, c using bowel necrosis nd
er or tion. One gnet should not c use ny trouble, but
two should be t ken seriously. Button batteries lodged in the
Objectives: Did you learn to . . . esophagus need to be removed emergently. However, once a
• Describe common causes o respiratory distress in children? button battery transitions to the stomach, it will likely pass
• Manage pediatric airway problems? without causing any di culty. However, it should be re-
• Treat children with croup? moved i it remains in the stomach or more than 48 hours

or is ≥ 15 mm. Other s ooth or rounded objects re unlikely to c lciu st bilizes c rdi c cell e br nes within 1 inute.
c use ny trouble. Even s ll sh r objects ( ush ins) gener lly C lciu glucon te 1 g or c lciu chloride 1 g y be given.
ss without c using er or tion or other signi c nt d ge. C lciu chloride is irrit ting to veins nd y c use necrosis
i it extr v s tes: centr l line d inistr tion is re erred. All o
CASE 1.25 the other nswers do lower ot ssiu levels (including continu-
ously nebulized lbuterol), but when there is evidence o ECG
A 67-year-old emale with a history o dialysis presents ch nges, giving c lciu is your to riority. T e other gents
slumped over and complaining o generalized weakness. y t ke s long s 30 to 60 inutes to ct. As note, bic rbon-
By the time she is in a room, her eyes are closed, she is non- te y not be rticul rly e ective in tients with end-st ge
verbal, withdraws rom pain ul stimuli and does not ollow ren l dise se, nother re son to use c lciu rst in this tient.
commands but has a palpable pulse at 80 beats per minute.
Her husband notes that she has been using “light salt,” which A er two doses o calcium gluconate, the QRS narrows and
contains potassium. You remember the “coma cocktail” you want to get the excess potassium out o your patient’s
rom earlier in this chapter: glucose, naloxone, thiamine and body.
oxygen. You also remember that not all narcotic overdoses
are associated with pinpoint pupils. You treat her appropri- Question 1.25.3 Which o the ollowing removes potassium
ately. T e patient’s blood sugar is 211 mg/dL. T e patient’s rom the body?
husband states that dialysis was not per ormed today. T e A) He odi lysis.
patient also missed her last dialysis appointment 2 days ago B) Insulin/glucose.
because she elt ill at home. Her mental status is unchanged C) K yex l te (sodiu olystyrene)
a er the “coma cocktail”; she is unable to protect her airway. D) Albuterol.
Husband con rms patient is ull code. You decide to proceed E) A nd C.
with intubation.
Answer 1.25.3 The correct answer is “E.” Both he odi lysis
Question 1.25.1 The best medications to use in this patient nd sodiu olystyrene will re ove ot ssiu ro the body.
are (induction agent/paralytic agent): Insulin/glucose will drive it intr cellul rly in 30 to 60 inutes
A) Eto id te/succinylcholine. but does not rid the body o ot ssiu . Be c re ul: sodiu oly-
B) Eto id te/ket ine. styrene exch nges sodiu or ot ssiu nd thus y worsen
C) Eto id te/rocuroniu . congestive he rt ilure. T e use o sodium polystyrene with
D) An induction gent nd r lytic re unnecess ry in this sorbitol is discouraged. It is ssoci ted with bowel ische i
tient since she is only res onsive to dee sti uli. nd necrosis. In addition, be care ul using sodium polysty-
rene in those with GI problems (ileus, stricture, etc.) or the
Answer 1.25.1 The correct answer is “C.” Rocuroniu would be same reason. Note th t tiro er, new ot ssiu binder, h s
the r lytic o choice in this tient. In tient with end-st ge recently been roved or use in the United St tes. However, it
ren l dise se on he odi lysis, ssu e the resence o hy erk - y not lower ot ssiu or u to 7 hours er d inistr tion
le i until roven otherwise. Succinylcholine y c use hy er- nd is NO roved or the cute lowering o ot ssiu .
k le i ( nd c rdi c rrest) so it is contr indic ted in tients
with high likelihood o hy erk le i . Succinylcholine should T e patient does well and, in the uture, knows to avoid
lso be voided in crush injuries, neurologic injuries/ yo - “light” salt (KCl) (o course, “light” is now spelled “lite” or
thies, nd burn tients where it y c use lign nt hy er- some unknown reason).
ther i . A sed tive should be used or induction to revent in
nd either eto id te or ket ine y be used—not both. Objectives: Did you learn to . . .
• Describe contraindications o succinylcholine in intubation?
You secure the irw y. A S A ot ssiu returns t 7.9.
D rn! You look t the onitor nd notice the QRS is looking • Treat hyperkalemia in the acute situation?
little wide. Double d rn!

Question 1.25.2 While you are waiting or an ECG to be

obtained, you administer:
CASE 1.26
A) K yex l te. A 24-year-old male presents to your ED complaining o
B) Sodiu bic rbon te. “dental pain.” He reports a long history o poor dental hygiene
C) C lciu glucon te. and has not seen a dentist in several years. He smokes two
D) Insulin/glucose. packs o cigarettes per day (and proudly wears a “Marlboro”
E) Albuterol nebulizer. hat) and admits drinking a 2 liter bottle o “Hillbilly Holler”
every day at work (it includes a ree coupon or dental service
Answer 1.25.2 The correct answer is “C.” In hy erk le i a er 100 bottles, but he has never availed himsel o this). T e
with evidence o ECG ch nges ( e ked w ves, wide QRS, pain is described as constant and throbbing in nature located
sine w ve), c lciu needs to be d inistered i edi tely. T e in the right lower jaw area.

Question 1.26.1 What ndings during your examination or a mild sore throat and given a “Z-Pak” (azithromycin—
would raise your concern regarding the patient’s clinical mostly on a whim). He has gotten progressively worse. Chest
condition? x-ray shows in ltrates and small abscesses.
A) L rge ounts o secretions.
B) Decre sed bility to o en his outh or the ex in tion. Question 1.26.3 Your presumptive diagnosis is:
C) Swollen nd elev ted tongue. A) Mononucleosis.
D) P in nd decre sed r nge o otion o the neck. B) Fusobacterium.
E) All o the bove. C) Arcanobacterium hemolyticum.
D) Vir l URI
Answer 1.26.1 The correct answer is “E.” I tient is h v-
ing trouble sw llowing secretions (“A”), it should r ise concern Answer 1.26.3 The correct answer is “B.” Fusobacterium is
or swelling in the osterior h rynx which c n co ro ise n n erobic in ection th t h s been ound with incre sing
not only the bility to sw llow one’s s liv but c n lso sign l requency in dolescent/college ge tients. It c n initi lly
high risk or u er irw y occlusion second ry to swelling. resent si il rly to stre thro t but y go on to “Le ierre
ris us (“B”) is lso concerning bec use it y indic te dee er syndro e,” which is se tic thro bo hlebitis o the intern l
in ection involving the uscles o stic tion. “C,” swollen jugul r vein. T is c n then le d to se tic e boli to the lungs,
nd elev ted tongue, y indic te the develo ent o Ludwig se sis, nd ultiorg n ilure. T e oint here is th t enicillin
ngin , li e-thre tening in ection o the oor o the outh, is still the drug o choice or stre thro t, nd it covers Fusobac-
which c n s re d to the dee er tissues o the sub ndibu- terium, which the crolides do not. As or the other nswers,
l r nd sub xill ry s ces. “D,” in nd decre sed r nge o this is not likely ononucleosis (“A”), since the neck swelling is
otion o the neck, could indic te the ossibility o retro h - unil ter l nd tients with ono usu lly re not this toxic nor
rynge l bscess. h ve in ltr te on chest x-r y. “C,” A. hemolyticum, is lso co -
on in college ge students nd is initi lly clinic lly indistin-
HELPFUL TIP: guish ble ro stre thro t. However, 50% o tients will h ve
Adult epiglottitis o ten presents with sore throat and culo ul r or sc rl tini or r sh st rting on the extre i-
neck tenderness. So, i the patient has neck tenderness ties nd involving the trunk nd b ck but s ring the he d; s
out o proportion to what you would expect, consider o osed to the r sh o sc rlet ever the r sh does not eel. It
epiglottitis or a retropharyngeal abscess. r rely c uses inv sive dise se such s neu oni or eningitis.
It will res ond to erythro ycin or clind ycin nd less so to
enicillin. “D” is obviously incorrect nd i you chose this one,
Luckily, the patient is otherwise clinically stable aside rom b ck to edic l school or you!
the ocal dental pain. Your examination shows the tissues
around tooth number 29 (we can never remember that pesky T e patient spends 3 weeks in the ICU and eventually suc-
numbering scheme either) to be swollen and inf amed with cumbs to his disease. Not good (way or us to end on a
signs o f uctuance and severe tenderness on palpation. An “downer” you say, but at least you get the message that
orthopantogram shows a periodontal abscess. “Z-paks” aren’t always the answer!).

Question 1.26.2 Which antibiotic is NOT an appropriate Objectives: Did you learn to . . .
• Identi y Fusobacterium and Arcanobacterium in ections?
choice or this clinical condition?
A) Penicillin VK. • Initial treatment o dental abscesses?
B) Clind ycin.
C) A oxicillin/cl vul n te.
D) ri etho ri –sul ethox zole. Clinical Pearls
Avoid CT scans in patients with known urolithiasis who have
Answer 1.26.2 The correct answer is “D.” Penicillin VK, the same symptoms again unless you suspect a postobstruc-
clind ycin, nd oxicillin/cl vul n te ll rovide good cov- tive in ection or have reason to believe it could be an aortic
er ge or n erobic b cteri including n erobic Gr -neg tive problem (e.g., at-risk patients over 50 years old).
cocci, which re the in cul rits in dent l in ections. MP– Avoid the use o narcotics or migraine headaches i possible.
SMX h s so e Gr -neg tive cover ge but l cks the n erobic Prochlorperazine or metoclopramide work well with pro-
cover ge needed to tre t in ections o the or l c vity. chlorperazine IV being the pre erred agent.
Do not do a chest CT i a patient is PERC negative or is low
T e same gentleman returns to you 3 weeks later complaining risk or a PE and has a negative d-dimer. Besides the expense,
o a sore throat. On examination, he looks toxic and has ever, the cancer risk or a 20-year-old emale rom a single 64 slice
chills, dyspnea/cough, and unilateral neck swelling. His throat chest CT is approximately 1 in 250.
looks similar to a streptococcal tonsillitis. However, the neck Do not do a head CT or patients with simple syncope: syn-
is tender and this guy really looks sick. Pulse is 130 bpm and cope is not a brain disease. It is generally a problem o CNS
BP is 80/50 mm Hg. He was seen last week by someone else

Frithsen IL, Si son WM Jr. Recognition nd n ge-

per usion; you have to knock out both hemispheres simulta-
ent o cute edic tion oisoning. Am Fam Physician.
neously to lose consciousness.
Do not do a head CT in low risk patients with head trauma. Green NE, Allen L. V scul r injuries ssoci ted with disloc -
Use a prediction rule. However, it is reasonable to CT those tion o the knee. J Bone Joint Surg Am. 1977;59:236–239.
on anticoagulants.
Herz AM, et l. Ch nging e ide iology o out tient b ctere-
Do not do a head CT looking or the cause o vertigo; it is i in 3- to 36- onth-old children er the introduction
almost always useless. I you need imaging, do an MRI but o the he t v lent-conjug ted neu ococc l v ccine.
recognize that and MRI will be negative or posterior circula- Pediatr In ect Dis J. 2006;25:293–300.
tion stroke in 30% o cases within the irst 24 hours. Hu JS, et l; ACEP Clinic l Policies Co ittee. Clinic l
Do not do a head CT o children with a irst uncomplicated Policy: critic l issues in the ev lu tion nd n ge ent
seizure. o dult tients resenting to the e ergency de rt ent
Do not get back imaging or acute low back pain unless there with seizures. Ann Emerg Med. 2014;63:437–447.
are red lags, such as: ever, cancer history, signi icant trauma Isbister GK, Ku r VV. Indic tions or single-dose ctiv ted
(not just twisting or picking something up), neurologic symp- ch rco l d inistr tion in cute overdose. Curr Opin Crit
toms or signs. Care. 2011;17:351–357.
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Sciences; 2010.
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S eci c oisonings. Chest. 2003;123:897–922.
Mosc ti RM, et l. A ulticenter co rison o t w ter ver-
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g strointestin l decont in tion. Clin Toxicol (Phila). h ving yoc rdi l in rction? JAMA. 1998;280:1256–1263.
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Brown CV, et l. Preventing ren l ilure in tients with North Am. 2004;22:887–908.
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Diercks DB, et l; ACEP Clinic l Polices Co ittee. Clinic l onoxide oisoning. Ann Emerg Med. 1995;25(4):481–483.
Policy: critic l issues in the ev lu tion nd n ge ent o Wol SJ, et l; ACEP Clinic l Policies Co ittee. Clinic l Poli-
dult tients with sus ected cute nontr u tic thor cic cy: critic l issues in the n ge ent o dult tients re-
ortic dissection. Ann Emerg Med. 2015;65:32–42. senting to the e ergency de rt ent with cute c rbon
Engebretsen KM, et l. High-dose insulin ther y in bet - onoxide oisoning. Ann Emerg Med. 2008;51:138–152.
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K mbe S. De c u and Ma k A. G abe
risk actors is only one consideration in the evaluation o this
CASE 2.1 patient. Smoking, hypertension, amily history, etc., do not
A 35-year-old emale presents with a 1-hour history o chest change the prior probability o cardiac disease enough to allow
pain, which resolved spontaneously. T e pain is described them to be used to rule out or rule in cardiac disease. O note,
as a chest pressure radiating to both arms. T e patient is a male gender and diabetes DO increase the pretest probabil-
smoker but has no other risk actors (no amily history o car- ity o coronary artery disease (CAD) (luckily our patient is a
diac disease, hypertension, diabetes, hyperlipidemia, etc.). woman!). Evaluation o pretest probability is important in the
T e patient is diaphoretic and has a normal blood pressure. diagnostic algorithm, but should be used in addition to, not in
Physical examination reveals that the patient has tenderness exclusion o , clinical judgment and ndings. “D” is incorrect. It
to palpation o the anterior chest wall that reproduces the is true that chest pain reproduced by palpation o the chest wall
chest pressure. She is now otherwise ree o chest pain and all makes cardiac disease less likely. However, 15% o patients with
her lab assays, including cardiac enzymes, are normal. cardiac disease and 17% o patients with a pulmonary embolism
(PE) will have their pain reproduced by chest wall pressure. T is
Question 2.1.1 Which o the ollowing is true about this does not mean that you are making their cardiac pain worse. It is
patient’s physical ndings and history? likely because o the patient’s inability to discriminate between
A) Pain radiating to both arms makes it unlikely that this the types o pain (cardiac vs. chest wall).
patient’s pain is cardiac.
B) T e physical ndings that are most highly associated with You decide that urther testing is warranted, including an
an acute myocardial in arction (AMI) include hypotension, ECG and cardiac enzymes.
diaphoresis, and a new S3 gallop.
C) T e absence o risk actors makes it unlikely that this patient Question 2.1.2 Which o the ollowing statements is TRUE?
has cardiac disease. A) A normal initial ECG in the emergency department (ED)
D) T e act that the pain is reproducible on palpation o the e ectively rules out cardiac disease.
chest wall e ectively rules out cardiac disease. B) Creatine phosphokinase MB raction (CPK-MB) is more
E) Based on the in ormation available, urther cardiac evalua- sensitive but less speci c than troponin.
tion is unnecessary. C) Serum troponin is an unreliable marker o cardiac ischemia
in patients with renal ailure.
Answer 2.1.1 The correct answer is “B.” T e ndings that D) T e serum troponin is 100% speci c or myocardial in arc-
are most likely to be associated with an AMI are hypoten- tion.
sion, diaphoresis, and a new S3 gallop. “A” is not true because E) A normal troponin and CPK in the ED cannot be used to
pain radiating to both arms can still be associated with car- make decisions about who to admit.
diac disease. In act, compared with le arm radiation, right
arm radiation or bilateral arm radiation doubles the likeli- Answer 2.1.2 The correct answer is “E.” Except in cases where
hood o the pain being cardiac (LR 2.3 or radiation to the le the chest pain has been continuous or over 12 hours, normal
arm vs. LR 4.1–4.7 or radiation to the right or bilateral arms). cardiac enzymes (troponin, CPK-MB) do not rule out cardiac
(JAMA. 2005;294(20):2623–2629.) Women with AMI o en pres- disease. I they did, we would not admit patients or a “rule out”
ent atypically and may experience more chest pain radiating to the but would rather rely on the single level drawn in the ED. “A” is
right arm/shoulder and the anterior neck or with abdominal incorrect since 9% o patients with AMI will have a normal ini-
pain as compared with men. “C” is incorrect. T e absence o tial ECG in the ED. In act, only about 50% o those with AMI
CHAPTER 2 • CAr Dio l o Gy 41

have a diagnostic ECG in the ED. Even a normal ECG obtained Question 2.1.4 Which o the ollowing drug(s) is/are indi
during chest pain does not reliably rule out AMI (Acad Emerg cated in the initial management o this patient?
Med. 2009;16:495). “B” is incorrect since the CPK-MB is over- A) Aspirin.
all less sensitive than a high sensitivity troponin. CPK-MB and B) T rombolytic such as tPA or streptokinase.
myoglobin may become positive earlier than the troponin. C) Heparin.
However, CPK-MB and myoglobin add little, i anything, to the D) Glycoprotein IIb/IIIa inhibitor (e.g., apciximab [ReoPro]).
troponin; many labs no longer per orm these assays in house. E) All o the above.
Eighty percent o AMIs will have one positive marker within the
rst 3 hours o ED arrival (but 20% will not). “C” is incorrect. Answer 2.1.4 The correct answer is “A.” Immediate therapy
Patients with renal disease may have a mildly elevated troponin in the ED requires ASA 325 mg orally (chewed). Since we are
at baseline due to poor clearance, but troponin can still be use- not sure that this patient has AMI or unstable angina, there is
ul in these patients i it continues to rise. It may be use ul to no indication or thrombolytic therapy (“B”), heparin (“C”) or
have knowledge o the patient’s baseline troponin in renal ail- glycoprotein IIb/IIIa inhibitor (“D”). Since she is currently pain
ure, but this is NO an indication to start drawing a baseline ree, heparin carries more o a risk than a bene t at this junc-
troponin on all o your patients with renal ailure. “D” is incor- ture and is not recommended. However, all patients with pos-
rect because we now know that other processes, such as PE, can sible angina or an AMI should have aspirin unless they are truly
elevate the serum troponin. allergic (hives, anaphylaxis). “B” is incorrect because thrombo-
lytics are indicated or acute S elevation myocardial in arctions
HELPFUL TIP: (S EMI), not or a simple chest pain evaluation.
E evated t p n n eve s ma be due t c nd t ns the
than AMi, nc ud ng hea t a u e, PE, bu ns, seps s HELPFUL TIP:
the c t ca ness, st ke, and m e. Sh u d “Mo NA (m ph ne, x gen, n t g ce n, as-
p n) g eet a pat ents,” as the ed t s ea ned n med
sch ? Pe m e ecent 2010 C ch ane Database S s-
HELPFUL TIP: temat c r ev ew, the e cac x gen n AMi has been
The new u t a-sens t ve t p n n ma be p s t ve w th n quest ned and ma even be det menta n th se w th
3 h u s. y u need t kn w what test u h sp ta s a n ma x gen satu at n (94% g eate , C ch ane
d ng. T p n n eve s peak n ab ut 36 h u s a te an Database S st r ev. 2010;6:CD007160). S , w thh d x-
n a ct and ma sta e evated 7 t 10 da s, s the gen un ess the x gen satu at n s <94%. M ph ne
n a ct ma have ccu ed an whe e w th n th s t me sh u d be used n a te a pat ent a s spec c the a-
ame. F w the t end the t p n n t he p dete - p , such as asp n and n t g ce n. And n t g ce n
m ne when the n a ct ccu ed. d es n t change n a ct s ze.

Question 2.1.3 All o the ollowing statements are true HELPFUL TIP:
EXCEPT: Cu ent use wa a n asp n sh u d not p ec ude
A) All myocardial in arctions present with chest pain. the adm n st at n asp n n the ED a pat ent
B) Dyspnea may be the only presenting symptom o myocar- w th chest pa n that ma be ca d ac n g n. y u neve
dial in arction. kn w whethe the pat ent s actua tak ng t n t. S ,
C) Patients with myocardial in arction can present with syn- un ess the e s a ea a e g t asp n, t must be g ven
cope. t chest pa n pat ents n the ED.
D) Females, the elderly, and diabetic patients are more likely to
present with atypical symptoms o myocardial in arction.
T e patient tells you that she is allergic to aspirin, which
Answer 2.1.3 The correct answer is “A.” As the saying goes, causes hives and bronchospasm. She can, however, take other
“Never say never, and never say always.” Many elderly and nonsteroidal anti-in ammatory drugs (NSAIDs) without
diabetic patients (“D”) will present with atypical symptoms or di culty. Oh, great. Now you need to go to plan B (no, not
painless, “silent” myocardial in arctions. In act, up to 30% o the “morning a er pill”).
myocardial in arctions are pain ree. “B” is a correct statement
because, especially in the elderly, dyspnea may be the only pre- Question 2.1.5 Which o the ollowing is an acceptable
senting symptom due to le ventricular ailure secondary to substitute or aspirin in this situation?
ischemia. “C” is a correct statement because syncope (as well as A) Dipyridamole.
lightheadedness and atigue) can be presenting symptoms o a B) Clopidogrel (Plavix).
myocardial in arction. C) Ibupro en or naproxen.
D) Celecoxib (Celebrex).
Her ECG shows nonspeci c S - changes. E) Salsalate.
42 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW

Answer 2.1.5 The correct answer is “B.” Clopidogrel in a Answer 2.1.6 The correct answer is “E.” Only a small majority
loading dose o 600 mg can be used as a substitute or aspi- (59%) o patients with pulmonary emboli have pain as a eature.
rin in the setting o unstable angina or AMI. “A” is incorrect “A” is incorrect because about 20% o patients with cardiac pain
because dipyridamole (in combination with aspirin) is indi- will have their pain relieved by a GI cocktail. Conversely, “D” is
cated only or stroke prevention. Dipyridamole itsel is a rela- incorrect because nitroglycerin can relieve pain rom esopha-
tively weak platelet inhibitor. “C” is incorrect because ibupro- geal spasm as it is a nonselective smooth muscle relaxer. “B” is
en and naproxen are reversible platelet inhibitors that do not incorrect because only 50% o patients with an aortic dissec-
give adequate platelet inhibition and have NO been shown to tion will have unequal pulses and blood pressures, and only
be o bene t in angina/AMI. In addition, both ibupro en and 75% will have an abnormal chest x-ray. T e consideration o an
naproxen can block the e ect o aspirin by making its binding aortic dissection mandates a chest C scan with contrast, trans-
sites on platelets unavailable. In act, stopping NSAIDs in any esophageal echo, or angiogram. Remember that about 20% o
patient being admitted or possible CAD is considered good the population will have unequal blood pressures in the upper
practice; they increase the risk o a cardiac event. “D” and “E” extremities at baseline. “C” is incorrect because most patients
are both incorrect because celecoxib and salsalate have not been with spontaneous pneumothorax can be treated with a “pigtail”
shown to inhibit platelets to a signi cant degree and thus would catheter with a Heimlich valve. T is type o treatment reduces
be o no use in this situation. the morbidity associated with a chest tube.

Chest x- a nd ngs n pat ents w th th ac c a t c d s-
N te that the ad ng d se c p d g e has been n-
sect n ma nc ude w dened med ast num, b te ated
c eased m 300 t 600 mg. But e the s ke an accept-
a t c kn b, p eu a “capp ng,” t achea dev at n, de-
ab e answe n the b a d exam nat n (and n p act ce).
p ess n e t ma n stem b nchus, es phagea dev a-
Newe ant p ate et agents, such as p asug e (E ent) and
t n, and ss the pa at achea st pe.
t cag e (B nta) a e bec m ng m e w de used as
ad ng agents. H weve , b eed ng sks a e h ghe w th
the newe agents.
T e patient’s pain recurs in the ED. You suspect that she is
having a myocardial in arction, but do not yet have unequiv-
ocal proo , such as ECG changes or elevated cardiac enzymes.
HELPFUL TIP: T e patient becomes markedly hypotensive in response to
o the NSAiDs (except asp n), nap xen appea s t another dose o sublingual nitroglycerin.
ca the west ca d ac sk. H weve , t has m e Gi
s de e ects. C x-2 nh b t s, such as ce ec x b, and Question 2.1.7 Which o the ollowing is TRUE?
d c enac a e Gi end but have m e adve se ca - A) Intravenous nitroglycerin is contraindicated in this patient.
d ac events. ibup en acts m e ke nap xen (l ancet. B) Hypotension caused by nitroglycerin is usually unrespon-
2013;382(9894):769–779). Guidelines suggest stop- sive to IV saline.
ping all NSAIDs except aspirin upon admitting a C) Hypotension caused by nitroglycerin may be indicative o a
patient for ACS or a question of ACS. Please do not right ventricular in arction, which is most commonly asso-
use ketorolac to treat chest pain as this is also an ciated with an in erior wall myocardial in arction (IAMI).
NSAID. D) Hypotension caused by nitroglycerin is diagnostic o car-
diogenic shock, suggesting that this patient will have a poor
Well, not all chest pain is cardiac, and this patient may have
another cause or hers. Answer 2.1.7 The correct answer is “C.” Hypotension in
response to nitroglycerin may be indicative o a right ventricu-
Question 2.1.6 Which o the ollowing is TRUE? lar in arct, which is most commonly associated with an in erior
A) Giving a “GI cocktail” (e.g., combination o Maalox and wall MI (IAMI). Since the right ventricle is dependent on lling
viscous lidocaine) can reliably di erentiate cardiac rom pressure (preload), nitroglycerin, which drops the preload, will
esophageal/GI causes o chest pain. requently result in hypotension in those with a right ventricu-
B) A normal chest radiograph and symmetrical pulses in the lar in arct. “A” is incorrect because hypotension rom sublingual
upper extremities reliably rules out a thoracic aortic dissec- nitroglycerin is not a contraindication to additional nitrates
tion. once the patient’s blood pressure is stable. A typical sublingual
C) Most patients with a spontaneous pneumothorax should be dose is 400 µg (0.4 mg). A typical IV dose starts at 20 µg/min.
treated with a chest tube. T us, the sublingual dose is quite a bit larger than the IV dose.
D) I nitroglycerin relieves the chest pain, then the pain is cer- In such a situation, you could consider starting IV nitroglycerin
tainly cardiac. at 10 to 20 µg/min and titrating up as the blood pressure allows.
E) Pain is a nding in only about 60% o patients with a PE. “B” is incorrect because hypotension rom nitroglycerin will
CHAPTER 2 • CAr Dio l o Gy 43

generally respond to a saline bolus. “D” is incorrect. Certainly, saline does acutely) once right ventricular unction returns to
patients with cardiogenic shock will be hypotensive, but hypo- normal.
tension with nitroglycerin is a common result o the drug itsel
and does not de ne cardiogenic shock. T e patient’s pain continues despite treatment with nitro-
glycerin, and you obtain another ECG (Fig. 2-1).

HELPFUL TIP: Question 2.1.9 Which o the ollowing is TRUE regarding

C ns de h d ng beta-b cke s n n e wa acute this ECG?
Mi (iAMi), as these pat ents ten have b ad ca d a and A) T is injury pattern on ECG is most consistent with an ante-
hea t b ck. A s , bewa e at p ca p esentat ns rior wall MI.
iAMi such as nausea, v m t ng, and the Gi s mpt ms. B) In this situation, intervention in the cath lab with percuta-
H d beta-b cke s n th se w th h p tens n, hea t neous transluminal coronary angioplasty (P CA) and stent
b ck hea t a u e. placement is superior to tPA or other thrombolytic.
C) T is injury pattern on ECG is most consistent with pericar-
Question 2.1.8 Which o the ollowing is TRUE o patients D) T is injury pattern on ECG proves that this patient does not
with an IAMI? have an aortic dissection.
A) T ey will likely continue to have problems with right ven- E) T is pattern on ECG is totally ne. What, me worry?
tricular unctioning in the uture.
B) T ey will need to increase their salt intake in order to Answer 2.1.9 The correct answer is “B.” Intervention in the cath
increase preload and right ventricular lling pressure. lab with P CA and/or stent placement is superior to thrombo-
C) T eir right ventricular unction should return to normal or lytic therapy in the treatment o AMI, provided that the “door to
close to normal ollowing their in arction. balloon” time is 90 minutes or less. In cases where the patient is
D) A and B. located in a acility without a cardiac catheterization laboratory,
the patient may receive thrombolytic therapy. “A” is incorrect
Answer 2.1.8 The correct answer is “C.” Most patients will because this pattern is indicative o an in erior wall, not an ante-
have return o right ventricular unctioning ollowing a myo- rior wall, MI. You will note that this ECG shows S elevations
cardial in arction. “B” is incorrect because there will be no need in leads II, III, and aVF (in erior leads) along with reciprocal S
to increase right ventricular lling pressure (which is what IV segment depression in leads V1 and V2. An anterior wall MI is

FIGURE 2-1. ECG pat ent n quest n 2.1.9.

44 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW

de ned by S elevations in leads V3, V4, and V5, and an antero- TABLE 2-1A ACC/AHA GUIDELINES FOR THE
septal MI shows S elevations in leads V1, V2, and V3. For IAMI MANAGEMENT OF PATIENTS WITH ST-ELEVATION
concerning or RV in arction, consider “right-sided chest leads.” MYOCARDIAL INFARCTION
“D” is incorrect because patients with pericarditis should have
C ass 1 ec mmendat ns the use th mb t cs n
S elevations in all leads (although an ECG is only 80% sensitive
m ca d a n a ct n nc ude an o NE the w ng th ee
or pericarditis). “D” is incorrect because patients with an aortic ECG nd ngs:
dissection can present with an abnormal ECG that looks simi- • ≥1 mm ST-segment e evat n n at east 2 c nt gu us mb
lar to an in arct pattern. So, ECG changes do not prove that the eads
patient does not have an aortic dissection. “E” is just plain wrong • 1–2 mm ST-segment e evat n n at east 2 c nt gu us p ec d a
and you should be worried i you see this pattern!
• New c mp ete bund e b anch b ck that bscu es the ST segment
ana s s p us a h st suggest ve Mi
You now have all the evidence that you need to show that this And
patient is indeed having an ongoing myocardial in arction. • P esent ng 12 h u s s nce the nset pa n, age <75 ea s (a th ugh
Since your rural hospital is “just around the corner rom t eat ng th se >75 ea s age s st a c ass 2 ec mmendat n
be w)
nowhere,” stenting is not going to happen within 90 minutes.
You decide to initiate thrombolytic therapy. C ass 2 ec mmendat ns the use th mb t cs n m ca d a
n a ct n nc ude an o NE the w ng:
• ≥1 mm ST-segment e evat n n at east 2 c nt gu us mb
Question 2.1.10 All o the ollowing are true statements eads and age >75 ea s o r p esent ng 12–24 h u s a te nset
EXCEPT: n a ct n
A) Patients who are candidates or thrombolytics must have at • 1–2 mm ST-segment e evat n n at east 2 c nt gu us p ec d a
least 1 mm o S -segment elevation in at least 2 contiguous eads and age >75 ea s o r p esent ng 12–24 h u s a te the nset
n a ct n
limb leads or at least 1 to 2 mm o S -segment elevation in • B d p essu e >180 mm Hg s st c and >100 mm Hg d ast c
at least 2 contiguous precordial leads. n a pat ent w th a “h gh- sk” m ca d a n a ct n (e.g., the h gh
B) Patients who are candidates or thrombolytics must have an sk the Mi m t gates the wa n ng ab ut th mb t c use n
absence o prior history o hemorrhagic stroke within the unc nt ed h pe tens n)
past year.
r ep duced m Antman EM, et a . ACC/AHA gu de nes the
C) Patients who are candidates or thrombolytics should have
management pat ents w th ST-e evat n m ca d a n a ct n—
no active bleeding, including menstrual bleeding. execut ve summa . J Am C Ca d . 2004;44(3): 671–719. C p ght 2004,
D) Patients who are candidates or thrombolytics should have w th pe m ss n m E sev e .
no history o recent head trauma.
E) Patients who are candidates or thrombolytics should not be

Answer 2.1.10 The correct answer is “C.” While active inter-

nal bleeding is a contraindication to the use o thrombolytics,
menstrual bleeding is not. While there are no controlled trials,
anecdotal evidence suggests that thrombolytics are sa e with
menstrual bleeding. “A” is correct. In addition to these ECG
criteria, the presence o a new complete le bundle branch Class 3 “Absolute” contraindications to the use of thrombolytic
therapy in MI
block (LBBB) with characteristic MI pain also indicates that the
• P ev us hem hag c st ke at an t me st ke w th n the ast
patient may bene t rom thrombolysis. Patients with only S - 12 m nths
segment depression or a normal ECG, even with symptoms, do • Kn wn nt ac an a ne p asm
not bene t. “B,” “D,” and “E” are all true statements. Patients • Act ve nte na b eed ng (but n t menst ua b eed ng)
are not candidates or thrombolytics i they have recent head • Suspected a t c d ssect n
trauma, are pregnant, or have had a hemorrhagic stroke in the Relative contraindications to the use of thrombolytic therapy in MI
last year. T ere are additional criteria or and contraindications • Unc nt ed h pe tens n (>180/110 mm Hg) at the t me
to the use o thrombolytics. See ables 2-1A and 2-1B. p esentat n.
• H st b eed ng d athes s, ng ng ant c agu at n (iNr >2–3)
• T auma, nc ud ng t aumat c CPr w th n 2–4 weeks, maj su ge
HELPFUL TIP: w th n 3 weeks
“Fac tated PCi,” that s, adm n st at n th mb t cs • N nc mp ess b e vascu a punctu es (e.g., subc av an ne)
w th the ntent t pe m PCi w th n 2 m e h u s • inte na b eed ng w th n the ast 2–4 weeks
• P egnanc
g v ng th mb t cs has ve m xed (and m st nega-
• Pept c u ce d sease (b eed ng n t)
t ve) data. o utc mes a e w se (and n t just because PCi • Seve e, ch n c h pe tens n
s a “ escue” techn que at th s p nt). it ce ta n s NOT
the standa d ca e and, n act, s n nge c ns de ed r ep duced m Antman EM, et a . ACC/AHA gu de nes the management
as pa t the t eatment a g thm. i th mb t cs pat ents w th ST-e evat n m ca d a n a ct n—execut ve summa . J Am C
Ca d . 2004;44(3): 671–719. C p ght 2004, w th pe m ss n m E sev e .
CHAPTER 2 • CAr Dio l o Gy 45

ve sus p ma PCi s be ng c ns de ed, t s va uab e t TABLE 2-3 CLASS I INDICATIONS FOR PACEMAKER IN
c ntact the ca d g st at the cath cente t dete m ne PATIENTS WITH AN ACUTE MYOCARDIALINFARCTION
whethe he/she w u d ke th mb t cs be e t ans- New e t bund e b anch b ck + st-deg ee AV b ck
e —t m ng (b th m s mpt m nset and t ans e ) New ght bund e b anch b ck + e t ante p ste asc cu a
s cent a t the dec s n mak ng p cess. “r escue PCi” b ck + st-deg ee AV b ck
a ed epe us n a te th mb t c the ap sh u d M b tz t pe ii hea t b ck
be pe med as s n as g st ca p ss b e, dea Th d-deg ee hea t b ck
w th n the st 24 h u s, but No T w th n the st 2 t S mpt mat c b ad ca d a un esp ns ve t at p ne.
3 h u s p stth mb t c the ap .

importantly, the placement o a transvenous pacemaker should

not delay trans er or catheterization since a pacemaker may be
placed in the cath lab. However, apply an external pacemaker
r emembe t epeat the ECG after th mb t cs t
as required.
p ve that ST e evat ns have es ved. Ev dence suc-
cess u epe us n a te th mb t cs s suggested b :
T e patient requires heparin with the thrombolytic that you
nea sudden and c mp ete e e chest pa n, >70%
choose (and is indicated, by guidelines, or a minimum o
ST e evat n es ut n n the ndex ead sh w ng the
48 hours and pre erably or the duration o the index hospital-
g eatest deg ee e evat n, p us m nus the p es-
ization, up to 8 days or until revascularization is per ormed).
ence epe us n a h thm a.
Question 2.1.12 Which o the ollowing dosing regimens is
the best accepted or use in AMIs?
A er con erring with your closest cath center, you give a A) Enoxaparin 30 mg subcutaneously (SC) every 12 hours.
thrombolytic—and cross your ngers. Un ortunately, the B) Enoxaparin 1 mg/kg SC every 12 hours.
patient develops a new LBBB. In addition, the ECG shows C) Heparin 5,000 units bolus and a drip at 1,000 units per hour.
evidence o a rst-degree heart block (a prolonged PR inter- D) Heparin 100 unit/kg bolus with a drip at 25 units/kg/hr.
val), although the heart rate remains normal at 80 bpm. E) None o the above represents the best dosing option in this
Question 2.1.11 The proper response to this is to:
A) Insert a Swan–Ganz catheter to monitor central pressures. Answer 2.1.12 The correct answer is “B.” For anticoagulation
B) Insert a temporary pacemaker regardless o the heart rate. in AMI, the dose o enoxaparin is 1 mg/kg SC every 12 hours.
C) Administer atropine to this patient. “A” is incorrect since 30 mg SC every 12 hours is the dose or
D) Administer isoproterenol to this patient. DV prophylaxis, not or anticoagulation. “C” is incorrect. T is
E) Do nothing, other than observe this patient. is the classic way that heparin has been dosed but it is not the
best option listed. “D” is incorrect as well. T e correct dose or
Answer 2.1.11 The correct answer is “B.” For patients with heparin when given with a thrombolytic is 60 units/kg bolus
an AMI, a transvenous pacemaker should be inserted i she (maximum o 4,000 units) with a drip o 15 units/kg/hr (maxi-
develops (1) complete heart block, (2) second-degree heart mum dose o 1,000 units/hr), with rate adjusted to achieve an
block type II (Mobitz II), or (3) new LBBB with rst-degree AV activated partial thromboplastin time (aP ) o 1.5 to two
block. See ables 2-2 and 2-3 or more on arrhythmia and pace- times control ( or 48 hours or until revascularization). T e bot-
makers in the setting o AMI. “A” is incorrect because a Swan- tom line here is that either enoxaparin or heparin can be used in
Ganz catheter will be o no help in arrhythmias. “C” is incor- this setting, and they are more or less equivalent. I you choose
rect because atropine is indicated or symptomatic bradycardia to use heparin, do not use f xed dose heparin but rather weight-
and not or a bundle branch block. “D” is incorrect or the same based dosing. Also, keep in mind that in the United States, it is
reason as “C.” In addition, isoproterenol is arrhythmogenic and likely that most interventional cardiologists would pre er hepa-
is no longer recommended. “E” is incorrect because the patient rin over enoxaparin, due to both amiliarity with dosing as well
may rapidly progress into a complete heart block. O note and as drug pharmacology in the cath lab.


WITH INFARCTION D d u kn w that ST-e evat n Mi, an n t a d se
Ante m ca d a Bund e b anch b cks 30 mg IV enoxaparin (that’s ght— nt aven us)
n a ct n M b tz t pe ii sec nd-deg ee hea t b ck sh u d be g ven w th the first and only the first d se
th se age <75 ea s. The iV d se sh u d be g ven at
in e m ca d a B ad ca d a m:
n a ct n • M b tz t pe i sec nd-deg ee hea t b ck the same t me as the st 1 mg/kg subcutane us d se.
• Th d-deg ee hea t b ck D t!
46 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW

Question 2.1.15 The patient passes her stress test with y

T e patient receives her thrombolytic, enoxaparin, and trans- ing colors (and you pass your Board Examination). Patients
venous pacing, and she is admitted to the hospital to a moni- a ter a myocardial in arction should be routinely discharged
tored bed. You get a call rom the nursing staf 5 hours later. on all o the ollowing medications EXCEPT:
T e rhythm strip shows 3 PVCs per minute. Your patient A) Aspirin.
remains pain ree and is hemodynamically stable. B) Beta-blocker.
C) Continuous nitroglycerin (e.g., patch or isosorbide).
Question 2.1.13 The nurse (who has more than a ew gray D) HMG-CoA reductase inhibitor (“statin”).
hairs) would like an order or lidocaine. Your response is: E) Sublingual nitroglycerin or PRN use.
A) “Do it. Give the lidocaine.”
B) “Give amiodarone—it works better than lidocaine.” Answer 2.1.15 The correct answer is “C.” T ere is no ben-
C) “Give no antiarrhythmic at this point in time.” e t to scheduled nitrates unless needed or a speci c indica-
D) “Check labs including potassium and magnesium.” tion (e.g., recurrent angina). All postmyocardial in arction
E) C and D. patients should be discharged on aspirin, beta-blocker, statin,
nitroglycerin PRN, and an angiotensin-converting enzyme
Answer 2.1.13 The correct answer is “E.” T e use o lidocaine (ACE) inhibitor (i tolerated, o course). Also, per ACC NS E-
in this setting incurs no bene t and is proarrhythmic. T e same ACS guidelines, individuals treated with an ischemia-guided
is true or prophylactic amiodarone, which can cause torsades strategy (vs. early invasive strategy), a P2Y12 inhibitor should
de pointes, albeit at a lower requency versus other antiar- be continued or up to 12 months i there are no contrain-
rhythmics (such as quinidine, procainamide, sotalol, and newer dications (options include clopidogrel 75 mg daily, ticagrelor
Class III antiarrhythmic agents). In the setting o AMI, antiar- 90 mg BID). Finally, per ACC guidelines, all patients with
rhythmics may be indicated only or complex arrhythmias (PVC S -elevation MI or non-S EMI/unstable angina should be
couplets, triplets, nonsustained ventricular tachycardia [<30 discharged on an intensive lipid-lowering regimen with an
seconds], or >10 PVCs per minute). More than 90% o patients HMG-CoA reductase inhibitor (“statin”), such as atorvastatin
will have isolated PVCs in the peri-in arct period, and there is 40 to 80 mg per day.
no association with increased mortality. Correcting hypokale-
mia and hypomagnesemia can help to reduce arrhythmias, and
checking these labs is prudent.
in pat ents w th a h st acute c na s nd me
T e patient remains pain ree while in the hospital. She is
(ACS), stat n the ap we s the sk ecu ent Mi,
ready to be discharged 4 days later.
st ke, CAD- e ated death, and the need c na
evascu a zat n. Stat n the ap a te ACS s bene c a
Question 2.1.14 Which o the ollowing tests is the most
n Al l pat ents, nc ud ng th se w th a base ne l Dl
appropriate or this patient prior to discharge?
<70 mg/dl . D scha ge ACS pat ents n a stat n.
A) Coronary angiography.
B) Submaximal stress test.
C) Full Bruce protocol, symptom limited, stress test.
D) Spiral C to assess or coronary artery calci cation. Question 2.1.16 I this patient had a STEMI (or “Q wave” MI),
E) Family Medicine Board Examination. which o the ollowing statements would be TRUE?
A) Patients with a non-S EMI have the same, or perhaps a
Answer 2.1.14 The correct answer is “B.” Submaximal stress bit worse, outcomes long term than do patients with a
testing is considered the standard o care. Patients with a posi- S EMI.
tive submaximal stress test should be re erred or catheter- B) Patients with a non-S EMI have worse in-hospital outcomes
ization. Patients with a borderline stress test can be sent or a when compared with patients with a S EMI.
radionuclide study. Coronary angiography is not routinely rec- C) Unstable angina and non-S EMI can be readily di erenti-
ommended or all patients who have had a myocardial in arc- ated rom one another on presentation.
tion unless they are considered to be at high risk (continued D) None o the above is true.
symptoms, positive screening test such as submaximal stress
test, heart ailure, cardiogenic shock, etc.). “C” is incorrect Answer 2.1.16 The correct answer is “A.” Patients with a
because a symptom-limited, ull-protocol stress test should be non-S EMI actually have the same, or perhaps even slightly
done only 14 to 21 days a er an in raction. Finally, spiral C worse, outcomes long term as do patients with a S EMI. T is
(“D”) to assess or coronary artery calci cation has no role in makes sense; there is still myocardium le to in arct a er a
risk strati cation a er a myocardial in arction . . . their risk is non-S EMI. As to the other answers, patients with a S EMI
100%! Also, keep in mind that the weight o the clinical evidence do have worse in-hospital outcomes, and unstable angina and
avors trans er or early catheterization, especially or higher non-S EMI look similar on ECG with -wave inversion, etc.,
risk patients. “E” is the test YOU are studying or . . . right? Dis- but without the S elevations that are classically seen in a trans-
oriented already? It’s only Chapter 2! mural in arction.
CHAPTER 2 • CAr Dio l o Gy 47

Objectives: Did you learn to . . . medications, but the patient continues to have pain. You con-
• De ne the accu ac the n t a h st , ECG, and abs n the sult a cardiologist who suggests the use o a glycoprotein IIb/IIIa
d agn s s ca d ac d sease n the ED ce? inhibitor.
• r ec gn ze the e and s gn cance ( ack the e ) sk
act s, such as d abetes, am h st , sm k ng, and h pe - Which o the ollowing is true about the glycoprotein IIb/IIIa
tens n, n the dec s n whethe n t t adm t a pat ent inhibitors?
t the h sp ta chest pa n? A) T ey are best used in patients who are not candidates or
• Gene ate a d f e ent a d agn s s chest pa n? P CA and stenting.
• ident the es va us d agn st c tests n the eva uat n B) T ey cause no increase in the rate o intracranial bleeding.
chest pa n? C) T ey are use ul in all groups o patients with ACS.
• T eat a pat ent w th an AMi? D) T ey are most e ective in patients going to P CA and/or

QUICK QUIZ: Co r o NAr y CAl CiUM The correct answer is “D.” T e glycoprotein IIb/IIIa inhibi-
tors are most e ective in patients who are undergoing P CA or
stenting. T e GUS O V trial showed NO di erence in 30-day
You are seeing a 47-year-old male patient. His presenting com-
mortality in patients who were not scheduled or catheteriza-
plaint is chest pain. T e chest pain is right sided and is not
tion. T us, “A” is incorrect. “B” is incorrect because glycoprotein
associated with exertion. T e patient looks well conditioned
IIb/IIIa inhibitors do increase rates o intracranial and other
and admits (well, beams . . . the jerk) he exercises daily without
bleeding. “C” is incorrect because patients who have an ACS
any chest pain. On clinical examination, you nd that the chest
that is well-controlled with other drugs (e.g., heparin, metopro-
pain is reproducible on palpation o the anterior chest wall. He
lol, and ASA) are not likely to bene t rom glycoprotein IIb/IIIa
smokes one pack o cigarettes per day and has a blood pressure
o 135/87 mm Hg, a total cholesterol o 179 mg/dL, and HDL o
30 mg/dL. He takes no medication.
CASE 2.2
Which o the ollowing is RUE regarding the role o a coronary A 53-year-old male with a history o hypertension and smok-
calcium score in this patient? ing, but no amily history o cardiac disease, presents to your
A) Coronary calcium score may be a help ul tool in the evalu- o ce complaining o a chest pain. T e pain is substernal,
ation o this patient in combination with the Framingham radiates to his le arm, and is associated with exertion. T e
risk score. patient notes that this same pain has been going on or the
B) Coronary calcium score is a help ul tool in the evaluation o last 6 months and has not changed at all in duration, inten-
this patient independent o the Framingham risk score. sity, or characteristic. It generally lasts 5 minutes or so and
C) Coronary calcium score is only use ul in evaluating this resolves with rest.
patient once he has had an echocardiogram.
D) Coronary calcium score cannot provide use ul in ormation Question 2.2.1 You tell the patient that:
regarding cardiac unction. A) Without doing any test, you know that the probability that
this pain is cardiac is greater than 85%.
The correct answer is “A.” T e patient presented with a Fram- B) I his ECG in the o ce is normal, his pain is unlikely to rep-
ingham risk score o 13%, which places him in the intermedi- resent cardiac disease.
ate-risk category or 10-year cardiac risk. Coronary calcium C) Even with risk actors, his probability o having CAD with
scores may be use ul in those with an intermediate risk to help “typical angina” is still only 50% or so.
strati y risk (e.g., between 10% and 20% risk by Framingham D) T e only intervention indicated at this point are li estyle
per JAMA. 2010 28;303:1610 and JACC Cardiovasc Imaging. modi cations (e.g., stop smoking) and addressing his cho-
2015;8(5):579–596). T is remains controversial, however. Won- lesterol and hypertension.
der why we are talking about Framingham rather than the more E) It is likely that he has unstable angina.
recent and more popular ACC/AHA 2013 cholesterol guideline
(which we discuss later)? Coronary calcium scores have not (as Answer 2.2.1 The correct answer is “A.” A 50-year-old male
o the time o this writing) been studied using the new ACC/ with “classic” angina symptoms has greater than a 90% prob-
AHA guideline. ability o having CAD. “B” is incorrect because patients with
angina who are pain ree may have a normal electrocardiogram
(as will many patients with active angina or even a myocardial
QUICK QUIZ: Giib/iiia iNHiBiTo r S in arction). T us, his pain could still be cardiac in origin. “C” is
incorrect because, based on demographic data, his risk o CAD
You are seeing a patient in the ED with chest pain. T e ECG is much higher than 50%. “D” is incorrect because he needs a
shows elevated S segments in leads V1, V2, and V3 with recip- urther evaluation and treatment o his chest pain. “E” is incor-
rocal changes in eriorly. You have run through the “standard” rect since this pain represents “stable angina.” T ere has been
48 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW

no change in quality, duration, amount o exertion required to TABLE 2-4 CONTRAINDICATIONS TO EXERCISE
bring on symptoms, etc., eliminating unstable angina as a diag- STRESS TESTING
nosis. Use o tools such as the IMI Risk Score and/or Grace
Abs ute • Acute m ca d a n a ct n w th n 2 da s
Risk Model can assist in estimation o the level o risk and to
c nt a nd cat ns • D ssect ng aneu sm
help guide management decisions (see 2014 AHA/ACC NS E- • r ecent pu m na emb sm
ACS Guideline). • Act ve th mb ph eb t s
• BP > 200/120 mm Hg
• Hem d nam ca s gn cant a h thm as
Kn w u p etest p bab t ca d ac d sease be e • Seve e a t c sten s s
emba k ng up n test ng chest pa n. Th s va es b • Act ve m ca d t s, pe ca d t s, end -
ca d t s
age and t pe chest pa n. An app x mat n the
• inab t t c mp ete test
p bab t ca d ac d sease s as ws: • Unstab e ang na
Ma e, at p ca ang na: age 30 t 39 = 34%, age 40 t 49 =
r e at ve • l e t bund e b anch b ck
51%, age 50 t 59 = 65%, age 60 t 69 = 72%.
c nt a nd cat ns • M de ate a t c sten s s
Ma e, typica l a ngina : age 30 t 39 = 76%, age 40 t 49 = • H pe t ph c ca d m path
87%, age 50 t 59 = 93%, age 60 t 69 = 94%. • E ect te d stu bance
• H gh g ade AV b ck
Fema e, at p ca ang na: age 30 t 39 = 12%, age 40 t
• Tach a h thm as b ad a h thm as
49 = 22%, age 50 t 59 = 31%, age 60 t 69 = 52%. nc ud ng unc nt ed at a b at n
Fema e, typica l a ngina : age 30 t 39 = 26%, age 40 t
49 = 55%, age 50 t 59 = 73%, age 60 t 69 = 86%.

Answer 2.2.3 The correct answer is “A.” Stress testing is best

You send the patient home on aspirin with a prescription or suited to patients with an intermediate pretest probability o
sublingual nitroglycerin or PRN use and arrange or a stress cardiac disease (between 25% and 75%). “B” and “C” are incor-
test. rect since patients with a high risk o cardiac disease should go
directly to another study, such as thallium testing and stress
Question 2.2.2 All o the ollowing are considered absolute echocardiography. “D” and “E” are incorrect since these are
contraindications to exercise stress testing EXCEPT: not the best groups in whom to use exercise stress testing;
A) Le bundle branch block (LBBB). there will be a greater proportion o alse-positive results in
B) Presence o severe heart ailure. these low-risk patients. Exercise stress testing in these groups
C) Critical aortic stenosis. is best used to allay patient ears that they do not have cardiac
D) Myocarditis. disease, not to prove they do have cardiac disease. However, a
E) Unstable angina. alse-positive stress test may lead to other unnecessary inva-
sive testing!
Answer 2.2.2 The correct answer is “A.” An LBBB is a rela-
tive—not absolute—contraindication to stress testing. In the You decide to do an exercise stress test on this patient. It
setting o LBBB, there are already repolarization abnormalities turns out to be negative.
that limit the use ulness o the stress test. One should add an
imaging modality, such as myocardial per usion scanning, in Question 2.2.4 Your next step is to:
cases o LBBB. T e same holds or any baseline ECG pattern A) Reassure the patient that he does not have cardiac disease.
that would inter ere with S segment interpretation (baseline B) Suggest a chest C scan to rule out possible aortic aneu-
S changes, LBBB, LVH with repolarization changes involv- rysm.
ing the S - wave, intraventricular conduction delay, paced C) Schedule the patient or another cardiac test such as stress
rhythm, preexcitation, or S - changes due to digoxin therapy); echocardiogram, exercise myocardial per usion test, or
the stress test SHOULD include an imaging modality. T e rest angiography.
are all “absolute” contraindications to exercise stress testing. See D) Schedule the patient or endoscopy to rule out gastroesoph-
able 2-4 or a list o contraindications to stress testing. ageal disease as a cause o these symptoms.
E) Start an anxiolytic to treat the panic disorder, which is the
Question 2.2.3 Exercise stress testing is best suited to which underlying cause o his chest pain.
group o individuals?
A) Men with an intermediate probability o cardiac disease. Answer 2.2.4 The correct answer is “C.” T is patient who is
B) Women with a high risk o cardiac disease. in his 50s and who has a “classic” history or angina has greater
C) Men at a high risk o cardiac disease. than a 90% pretest probability o cardiac disease. T us, it is
D) Men at a low risk o cardiac disease. likely that the negative stress test is a alse negative. T us, a
E) Women with a low risk o cardiac disease. stress test probably should not have been done in this patient
CHAPTER 2 • CAr Dio l o Gy 49

in the rst place, since a negative test just leads to urther stressing this patient. Dobutamine is an acceptable method
testing (as would have a positive test, probably resulting in o chemically stressing those on theophylline or ca eine
angiography). For this reason, “A” is incorrect. “B,” “D,” and “E” (like us).
are incorrect. Initiating evaluation and management or another
cause o chest pain is premature, since we still have not proven Question 2.2.7 The patient’s thallium stress test shows an
that this patient does not have cardiac disease. anteroapical nonreversible (“ xed”) de ect. The best inter
pretation o this is that it indicates:
You are considering whether to do a thallium stress test or a A) Attenuation arti act rom breast tissue.
stress echocardiogram. B) Prior myocardial in arction.
C) Angina.
Question 2.2.5 Which o the ollowing is true? D) Anomalous cardiac circulation.
A) Stress echocardiography is more sensitive or cardiac disease E) It is not signi cant and there ore adds no value to this test.
than is a thallium test.
B) Stress echocardiography is more speci c than is stress thal- Answer 2.2.7 The correct answer is “B.” A nonreversible
lium. (“ xed”) de ect suggests prior myocardial in arction. A revers-
C) T allium testing is more speci c or cardiac disease than is ible de ect suggests inducible ischemia. “A” is incorrect since
stress echocardiography. breast attenuation occurs mostly in women (but can also be
D) None o the above is true. seen in obese males, which is part o the rationale or per orm-
ing PE in patients with BMI > 35 kg/m 2 since PE uses a
Answer 2.2.5 The correct answer is “B.” Stress echocardiogra- higher-energy isotope to mitigate so tissue attenuation). “C”
phy is more speci c or cardiac disease than is thallium test- is incorrect since angina would likely be mani ested by a revers-
ing. Alternatively, thallium testing is more sensitive. able 2-5 ible de cit.
summarizes this data. Remember that positive and negative
predictive values o these tests will vary depending on the pre- Since a reversible de ect was not ound on the thallium
test probability o disease in the patient and severity o disease. stress test, you conclude that there is no myocardium cur-
Numbers given above are overall. rently at risk. However, the patient continues to have chest
pain and now at an increasing requency with less exer-
You decide to send the patient or a thallium stress test. tion. He is asymptomatic when he presents to your o ice.
However, since his exercise capacity is limited, you choose to He was noted at the last visit to have an elevated glucose at
stress him chemically. T e patient is taking theophylline or 350 mg/dL.
chronic obstructive pulmonary disease (a pox on the doctors
still prescribing that drug!). Question 2.2.8 What is the next step in the evaluation or
treatment o this patient?
Question 2.2.6 The LEAST desirable method o stressing A) Stress echocardiogram to document what segments are
this patient is: involved.
A) Adenosine. B) Start the patient on insulin to control his blood sugars.
B) Dobutamine. C) Proceed directly to cardiac catheterization.
C) Dipyridamole. D) Since there were no reversible de cits on thallium stress,
D) All o the above are equally acceptable methods o chemi- schedule the patient to see a gastroenterologist.
cally stressing this patient. E) Give a trial o NSAIDs to help di erentiate chest wall pain
E) Neither A nor C is desirable. rom other causes.

Answer 2.2.6 The correct answer is “E.” heophylline (and Answer 2.2.8 The correct answe r is “C.” “A” is incorrect
ca eine) interacts with both adenosine and dipyridamole, since we already have done a noninvasive test. We already know
attenuating their e ect; thus, neither is a good choice or what segment was previously in arcted, as noted on the thal-
lium stress test. “B” is incorrect or two reasons. First, address-
ing his diabetes will not address the immediate problem o what
TABLE 2-5 OVERALL SENSITIVITY AND SPECIFICITY you must presume is unstable angina. Second, insulin is not
OF NONINVASIVE CARDIAC TESTING necessarily the rst drug to use in this patient who presumably
Sensitivity Speci city has type 2 diabetes. Certainly, the blood glucose needs to be
(%) (%) addressed and so does the chest pain. Which is going to kill him
rst? “D” is incorrect. T e sensitivity o thallium testing is in the
Exe c se st ess test ng 45–68 77
88% range (see able 2-5), so it will miss 12% o disease. T us,
Tha um st ess test ng (SPECT) 88 77 we still have not proven in this high-risk patient that he does
not have treatable cardiac disease causing his chest pain. “E” is
St ess ech ca d g aph 76 88
incorrect or the same reason.
50 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW

T e patient has a catheterization done that shows three-vessel HELPFUL TIP:

disease including le main CAD. T e cardiologist calls you A p ea m u ed t s. D n’t c nt nue c p d g e ,
with the report the next day and suggests P CA with stent- etc., uts de the t me ame n wh ch the have been
ing, since, in his opinion, “this is the best modality or dia- sh wn t be use u (3–6 m nths a bea meta stent,
betics and diabetics are high-risk candidates when it comes 1 ea a d ug e ut ng stent) un ess the e s ng ng
to surgery.” ACS. The b eed ng sk s nc eased n m n ma ben-
e t. C nt nue asp n nde n te , c u se (N Eng J Med.
Question 2.2.9 Your opinion is that: 2014;371:2225–2226). F pat ents n wa a n an the
A) Patients generally have better outcomes in terms o con- a ant c agu ant, c ns de at n sh u d be g ven t e-
trol o angina with stenting when compared with coronary duc ng the du at n t p e the ap ( a ant c agu ant +
artery bypass gra ing (CABG). ASA + c p d g e , examp e) due t b eed ng sk w th-
B) Diabetic patients do particularly well with stenting when ut s gn cant bene t. D p ne the ant p ate et d ugs.
compared with CABG. H weve , the pt mum du at n the ap has n t been
C) Medical control o symptoms is indicated as the best man- estab shed. it ma be sa e t st p t p e the ap as ea as
agement in this diabetic patient with three-vessel disease. 4 t 6 weeks a te a DES (J Am C Ca d . 2015;65:1619).
D) You would like to send this patient or CABG.
Your patient has a CABG and comes into your o ce com-
Answer 2.2.9 The correct answer is “D.” T is patient should
plaining o chest pain and ever 3 weeks a er the surgery. He
probably have surgery or his three-vessel disease because dia-
has had the pain and ever or 4 days and does not seem to
betic patients generally have worse outcomes with stenting than
be getting any better. He has no cough, no sputum produc-
do nondiabetic patients in terms o angina relie and need or
tion, and the pain seems to be worse when he breathes or lies
repeat revascularization. “A” is incorrect because a proportion
down. He reports no dyspnea and has 97%oxygen saturation
o patients with stents have to go on to have an open CABG due
on room air. T e wound rom the surgery is well healed, and a
to in stent restenosis or incomplete revascularization with per-
chest radiograph shows no evidence o abnormalities.
cutaneous revascularization. “B” is incorrect. Diabetic patients
have a much higher rate o in stent restenosis or secondary
Question 2.2.10 Which o these studies is LEAST likely to be
occlusion (meaning a narrowing/stenosis somewhere else in
abnormal in this patient?
the diseased vessel). “C” is incorrect. T e indications or CABG
are signi cant le main CAD (>50%), three-vessel disease with
B) V/Q scan.
evidence o LV dys unction (ejection raction <50%), or ori-
C) Echocardiogram.
gin/proximal LAD/LCX disease (le main equivalent). T is
D) Sedimentation rate.
patient has le main vessel disease and thus medical control
is NO the best option or this patient. He is also young and, Answer 2.2.10 The correct answer is “B.” A V/Q scan is not
rom the available data, appears to be a good surgical candi- likely to be positive in this patient. T is patient is unlikely to have
date. T ere ore, CABG is the guideline-recommended option a PE given the duration o symptoms, the act that the patient has
is this patient. chest pain that worsens with inspiration ( ound in only 59% o
those with PE), ever, absence o dyspnea, and has normal oxy-
gen saturation. Certainly, this could still be a PE, but it would
HELPFUL TIP: be less likely than other, more plausible, explanations. T e most
D ug-e ut ng stents (DES) dec ease ve a e cc us n likely diagnosis in this patient, given the lack o other symptoms,
ates n c mpa s n t ba e meta stents (BMS). W men is postpericardotomy syndrome. T is is similar to Dressler syn-
wh have mu t p e stents and mu t -vesse d sease a e drome, which occurs a er a myocardial in arction and presents
at a h ghe sk esten s s, as a e pat ents w th a sma with ever and chest pain several days to weeks a er the inciting
p ststent ng umen s ze. Ea e cc us n sec nda event. T e white blood count is o en elevated, as is the sedimen-
t th mb s s s h ghe w th DES ve sus BMS, and the tation rate. T e ECG can be help ul as can an echocardiogram.
m ta t sk due t stent th mb s s s h gh ( ange 20–
45%). Th s s because t takes the b d nge t c ve You obtain an ECG on this patient that shows a pattern con-
these stents w th nt ma ( .e., end the a zat n). Thus, sistent with pericarditis.
c p d g e , t cag e p asug e (n t u av te)
1 ea PLUS asp n e sh u d be used n pat ents Question 2.2.11 Which o the ollowing patterns can be
wh have a d ug-e ut ng stent nse ted. F ba e meta seen in a patient with pericarditis?
stents, the ec mmendat n s t use ne the ant - A) Di use S segment elevation.
p ate et agents 3 to 6 months PLUS asp n e. B) Normal ECG.
(N te: the sk stent th mb s s w th a ba e meta C) LBBB.
stent s h ghest n the st 14–30 da s.) D) A and B.
E) All o the above.
CHAPTER 2 • CAr Dio l o Gy 51

Answer 2.2.11 The answer is “D.” Both di use S segment

elevations and a normal ECG can be seen with pericarditis. He gets admitted to a cardiac inpatient bed and you give a
T e initial ECG is only 80% sensitive or pericarditis. Small bolus o IV saline. Despite this, he remains dyspneic with
(low voltage) QRS complexes or electrical alternans can also elevated neck veins and has a pulsus paradoxus o 14 mm Hg
be seen i there is a pericardial e usion. “C” is incorrect since (normal <10 mm Hg).
bundle branch blocks have nothing to do with pericarditis. You
will have a chance to look at an ECG o pericarditis later in the Question 2.2.14 The next step or this patient is:
chapter. Note: PR depression accompanying di use S eleva- A) Change the patient to steroids rom indomethacin.
tion +/– sinus tachycardia may also be seen in pericarditis. B) Per orm a pericardiocentesis.
C) Start a positive inotrope (e.g., dopamine) to improve right
A er a complete history, physical examination, ECG and heart unction.
echocardiogram, you determine that he has pericarditis. D) Start an a erload reducer to reduce cardiac demand.

Question 2.2.12 Which o the ollowing drugs might be Answer 2.2.14 The correct answer is “B.” T e patient is clearly
help ul in this patient? not doing well i he is getting more short o breath and not
A) Heparin. responding to your treatment. T e pulsus paradoxus is 14 mm Hg.
B) War arin. T is is indicative o possible cardiac tamponade, but it may be
C) Furosemide. seen in constrictive pericarditis, severe asthma, or anything else
D) Indomethacin. that reduces right heart lling (e.g., tension pneumothorax).
T is patient’s clinical picture is consistent with decompensated
Answer 2.2.12 The correct answer is “D.” Didn’t we just tell cardiac tamponade, and drastic action is indicated to relieve the
you not to use NSAIDs in patients who have CAD? Well, yes. symptoms o right heart ailure. T e de nitive treatment is peri-
However, in this particular case, an NSAID is indicated. Vari- cardiocentesis. “A” is incorrect because more drastic action is
ous doctors weighing risks and bene ts o NSAIDs in this required. You would be correct to change the patient to predni-
case might come to di erent conclusions, but o the available sone or to add colchicine. Colchicine is being increasingly used
options, “D” is the only one which is a treatment or pericarditis. or pericarditis. “C” is incorrect since an inotrope will do little
o treat pericarditis, you can use aspirin, another NSAID, ste- to help this problem. “D” is incorrect or two reasons: the rst
roid, or colchicine. Generally, indomethacin or aspirin are con- is that this is a right heart problem and reducing a erload (sys-
sidered rst-line drugs with steroids being reserved or those temic vascular resistance) will not help the right heart, which
who ail NSAID therapy. Colchicine is becoming increasingly pumps against pulmonary resistance; second, most drugs that
popular as a second-line treatment a er an NSAID. Do not use reduce systemic vascular resistance will also decrease preload to
anticoagulation, either heparin or war arin, in patients with some degree, worsening the symptoms o tamponade.
pericarditis. T is can cause bleeding into the pericardial space
and tamponade. T us, “A” and “B” are incorrect. “C” is incorrect
because urosemide will likely make this patient worse. Patients
Be awa e that up t 25% pat ents w th ca d ac tam-
with increased pericardial pressures are dependent on circulat-
p nade w NOT dem nst ate an e evated pu sus pa a-
ing preload volume in order to ll the right heart. Decreasing
d xus. S , a n ma pu sus pa ad xus d es n t u e ut
the preload may cause dyspnea in this patient. Steroids are not
ca d ac tamp nade.
rst line and are typically reserved or recurrence a er treat-
ment with NSAIDs and colchicine.
T e patient returns the next day and is now eeling short Measu ng pu sus pa ad xus: Pump up the BP cu
o breath. On examination, you notice JVD and peripheral t g eate than the s st c BP. De ate de ate BP cu
edema. s w and sten the st K tk s und hea d
only du ng exp at n; c nt nue s w de at ng unt
Question 2.2.13 The best initial treatment o this patient is: u hea the K tk s unds w th nsp at n as we .
A) Furosemide. The d e ence s the pu sus pa ad xus.
B) Nitroglycerin.
C) IV saline.
D) Morphine. You per orm a pericardiocentesis and the patient gets better.
O course, a good outcome never protected anyone rom a
Answer 2.2.13 The correct answer is “C.” T is patient is in
lawsuit . . .
“pure” right heart ailure secondary to possible cardiac tampon-
ade (eek! Let’s get him a cardiac inpatient bed!). He is preload Objectives: Did you learn to . . .
dependent. T e treatment is to increase his preload by using IV • Eva uate a pat ent w th t p ca ang na chest pa n?
saline. All the other options reduce the preload and will worsen • Desc be the test cha acte st cs va us t pes n n nva-
this patient’s symptoms. s ve ca d ac test ng?
52 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW

• Bec me am a w th the nte p etat n n n nvas ve The correct answer is “D.” According to JNC 8, the goal or a dia-
ca d ac test ng? betic patient (or any patient age 30–59 years, including those with
• r ec gn ze va us nd cat ns PTCA w th stent p acement chronic kidney disease) is <140/90. ighter control does not seem
ve sus CABG? to con er any bene t. T e BP goal in those over age 60 is <150/90.
• Unde stand the ph s g , p esentat n, and t eatment T ese goals are consistent with the best current evidence at the
p stpe ca d t m s nd me? time JNC 8 was published. In act, tight blood pressure control in
• T eat pe ca d t s and ca d ac tamp nade? diabetics increases mortality (JAMA. 2010;304(1):61–68).

QUICK QUIZ: CAr DiAC CT SCAN r ec mmendat ns t eat ng h pe tens n n the
e de va a tt e based n the gan zat n pub sh-
When planning or treatment or diagnosing (i.e., “ruling out” ng the g a s. F pat ents ve age 80 ea s, the e s
MI/acute ACS) based on a cardiac C angiogram (CC A), un ve sa ag eement (ACC/AHA, JNC 8, ASH, ESH/ESC)
which o the ollowing is true? that <150/90 sh u d be the g a . F pat ents age
A) CC A is associated with better long-term clinical outcomes 60 t 79 ea s, JNC 8 ec mmends a g a <150/90
than is cardiac per usion (thallium) scanning. wh e the the gan zat ns ec mmend a g a
B) T e radiation exposure or C angiogram is less than that o <140/ 90—but w th a s st c p essu e ema n ng g eat-
thallium scanning. e than 115 mm Hg.
C) T e downstream radiation exposure a er thallium scanning
is less than that o C angiogram.
D) T e C angiogram is best done in those with a pulse o 70 to CASE 2.3
80 bpm.
E) A creatinine o 1.6 mg/dl is a contraindication to the use o A 24-year-old male presents to your clinic with a 50-hour
C angiogram because o the contrast load. history o an irregular heart rate. He is generally well but
has a history o hypertension (too many super-jumbo burg-
ers . . . with bacon . . . he’s been “supersized”), which he has
The correct answer is “B.” T e radiation exposure o CC A been trying to control with exercise and diet (he switched
is less than that o thallium scanning, both initially and down- to to u burgers yesterday). T ere is no prior history o car-
stream (thus, “C” is wrong). More patients who have thallium diac disease or palpitations. He did “have a bit to drink” cel-
scanning go on to angiogram and additional radiation ex- ebrating . . . well, whatever, just celebrating . . . who needs
posure. “D” is incorrect. T e slower the heart rate, the better a reason! He was embarrassed about his drinking and thus
the images (within reasonable limits, o course . . . . as pulse o waited 2 days to seek care. T ere is no amily history o heart
12 BPM isn’t so good). So, patients are o en pretreated with disease and the patient does not smoke. Vital signs reveal an
metoprolol to slow the heart rate be ore CC A. “E” is also in- irregular pulse o 130 bpm and a blood pressure o 160/100
correct. It turns out that IV contrast is less o a actor in renal mm Hg. T e patient is a ebrile and has normal respirations.
ailure than we have thought (Radiology. 2014;273(3):714). I He has no heart murmur. T e ECG is shown below (Fig. 2-2).
you eel the patient really needs the C and has a creatinine o
1.7 mg/dl or less, go ahead with the C . Question 2.3.1 The most appropriate diagnosis is:
What about answer “A”? It turns out that even though CCTA A) Multi ocal atrial tachycardia (MA ).
is better at identi ying cardiac disease (CCTA is more sensi- B) Wandering atrial pacemaker.
tive) and leads to more interventions than is thallium scanning C) Atrial brillation.
and echo, its use is not associated with better outcomes. T is is D) Ventricular tachycardia.
true even though more patients who have had a CC A go on to E) Accelerated junctional rhythm.
have revascularization (N Engl J Med. 2015 Mar 14). Feel ree to
do that thallium test . . . . Answer 2.3.1 The correct answer is “C,” atrial brillation.
T is is characterized by the lack o P waves and an irregularly
irregular rhythm. “A” and “B” are incorrect. While both MA
QUICK QUIZ: HyPEr TENSio N and a wandering atrial pacemaker are irregularly irregular, both
have P waves. “D” is incorrect. Ventricular tachycardia is a wide
According to the members o the Eighth Joint National complex tachycardia and is regular. “E” is incorrect. While there
Committee (JNC 8), the blood pressure goal in a patient with are no P waves in an accelerated junctional rhythm, it should be
diabetes is: a regular, organized rhythm.
A) <100/50 mm Hg.
B) <110/70 mm Hg. Question 2.3.2 What is the most likely cause o this patient’s
C) <130/80 mm Hg. dysrhythmia?
D) <140/90 mm Hg. A) Congenital prolonged Q syndrome.
E) None o the above. B) Hypertrophic cardiomyopathy.
CHAPTER 2 • CAr Dio l o Gy 53

FIGURE 2-2. ECG pat ent n quest n 2.3.1.

C) Alcohol. brillation. Certainly, stroke and other intracranial injuries can

D) Marijuana use. be associated with arrhythmias. However, these are generally
E) Ischemic cardiac disease. isolated PVCs. Stroke may also be associated with heart ailure
and ischemic changes on the ECG, but it is rarely an isolated
Answer 2.3.2 The correct answer is “C.” T e most likely cause cause o atrial brillation. Valvular heart disease, hyperthyroid-
o atrial brillation in this 24-year-old is alcohol. T is is also ism, heart ailure, and PE are all causes o atrial brillation.
known by the moniker “holiday heart.” It occurs a er episodes Valvular heart disease, heart ailure, and PE all have a similar
o signi cant alcohol intake. T e underlying mechanism is not mechanism: stretching o the atrium leading to atrial irritability.
known, but alcohol is known to be cardiotoxic at higher vol- Atrial brillation is ound in 10% to 20% o those with hyper-
umes which varies per individual. “A” is incorrect because pro- thyroidism, especially in the elderly.
longed Q typically causes polymorphic ventricular tachycar-
dia (torsades de pointes). “B,” hypertrophic cardiomyopathy, is T e patient con des that he was indeed at a bachelor party
unlikely since the patient has never had a murmur, and hyper- several days ago (so that was what he was celebrating) and
trophic cardiomyopathy generally presents with signs o aortic had a bit too much to drink. T is is quite unusual or the
outlet obstruction (syncope or angina with exercise) although patient. He generally drinks 2 to 3 beers per week, but on
a subset o patients do not have obstructive physiology. “D” is this particular night had 12 or more (hmm . . . we’re wonder-
incorrect because marijuana is not implicated in causing atrial ing). T e patient’s pulse increases to 160 bpm, but he remains
brillation, and “E” is incorrect because a patient who is 24 asymptomatic.
years old is unlikely to have ischemic cardiac disease.
Question 2.3.4 The INITIAL goal or this patient with
Question 2.3.3 Other states that can cause atrial brillation 50 hours o atrial brillation is:
include all o the ollowing EXCEPT: A) Anticoagulation.
A) Valvular disease, especially mitral disease. B) Immediate cardioversion (DCCV).
B) Hyperthyroidism. C) ransesophageal echocardiogram to rule out vegetations.
C) Stroke. D) Rate control.
D) Heart ailure. E) Blood pressure lowering
E) Acute PE.
Answer 2.3.4 The correct answer is “D.” Since this patient has
Answer 2.3.3 The correct answer is “C.” Stroke does not had >48 hours o atrial brillation, rate control is the goal. I
generally cause atrial brillation but can be a result o atrial the onset o atrial brillation is indeterminate or >48 hours,
54 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW

one should withhold cardioversion. For those with <48 hours o provided. Some physicians will start heparin or low-molecular-
atrial brillation, cardioversion is a viable option. Anticoagula- weight heparin at the same time as initiation o war arin; how-
tion is also important to initiate while attempting to achieve rate ever, the combination is not strictly necessary in patients with
control. See more on whom to anticoagulate below. non-valvular atrial brillation. T is scenario is much di erent
than when patients have a PE/DV . For non-valvular atrial
T e patient’s heart rate remains elevated at 160 bpm with brillation, starting war arin alone is su cient. “B” is incor-
occasional orays into the 170 bpm range. rect. T ere is no need to bridge patients starting rivaroxaban
with heparin; rivaroxaban’s anticoagulant e ect is “immediate”
Question 2.3.5 Which o the ollowing is the best drug to and there is no transient hypercoagulable state. However, note
administer to this patient? that since he gave a history o an “irregular heart beat or 50
A) Digoxin. hours” on presentation, he has now presumably been in atrial
B) Lidocaine. brillation or >48 hours (approximately 74 hours at this point),
C) Amiodarone. so immediate cardioversion is contraindicated (see next ques-
D) Adenosine. tion). Heparin (“C”) or aspirin (“D”) alone would not be the
E) Diltiazem. best choices in this case.

Answer 2.3.5 The correct answer is “E.” “A” is incorrect. Question 2.3.7 How long must you wait a ter the patient
Digoxin will be o limited use since it takes at least 30 minutes has been anticoagulated be ore cardioverting him?
to have an e ect. It can be used in those with atrial brillation A) 1 week.
secondary to heart ailure but will still not signi cantly help B) 3 weeks.
with rate control—especially in younger patients with robust C) 3 months.
sympathetic tone. “B” is incorrect because lidocaine is indicated D) Only until therapeutic on war arin.
or a wide complex tachycardia. “C” is incorrect. Amiodarone E) T ere is no need to wait be ore cardioversion in this patient.
will work as a treatment o atrial brillation but is a second-line
drug because it can cause torsades de pointes. It can be used Answer 2.3.7 The correct answer is “B.” I the patient has been
in patients with atrial brillation and congestive ailure, where in atrial brillation or more than 48 hours, one should wait
verapamil or diltiazem might be contraindicated. Amiodarone or cardioversion until the patient has been anticoagulated or
is considered to be advantageous in maintaining sinus rhythm, 3 weeks with war arin (target INR 2–3) or standard dose riva-
especially when given as pretreatment prior to cardioversion, roxaban (Xarelto), apixaban (Eliquis), or dabigatran (Pradaxa).
but is not as e cacious in prompt heart rate control due to I atrial brillation has been present or less than 48 hours, you
longer onset o action. “D” is incorrect. Adenosine is ultra- can proceed directly to cardioversion. Some physicians may
short-acting, blocks the AV node, and can be used to convert a order a transesophageal echocardiogram to assess or throm-
paroxysmal supraventricular tachycardia (PSV ) or slow down bus ormation be ore cardioversion; this approach is acceptable.
the rate o the arrhythmia temporarily i you are not sure what T e patient will also need anticoagulation or 4 weeks a er
the diagnosis is (e.g., a rapid atrial f utter vs. PSV ). However, success ul cardioversion.
adenosine will not reduce the ventricular rate in atrial bril-
lation since atrial brillation does not require the AV node to
propagate. A beta-blocker could also be used in this situation. HELPFUL TIP:
r va xaban, ap xaban ( act Xa nh b t s) and dab -
Being the astute clinician that you are, you realize that 50%o gat an (a d ect b n nh b t ) a e a app ved use
atrial brillation will spontaneously convert to normal sinus n n n-va vu a at a b at n. The ch ce d ugs
rhythm, especially i present <72 hours. A transthoracic s up t u. The e s tt e c n ca d e ence between
echocardiogram was per ormed and did not demonstrate any utc mes w th wa a n, ap xaban and dab gat an (a -
structural heart disease. T us, you choose to give verapamil th ugh wa a n s ess expens ve, even when check ng
and watch the patient. At 24 hours, he still is in atrial brilla- iNr s). The e ma s me s ght c n ca advantage t va-
tion, although the rate is controlled well with verapamil and xaban. But, the e s n c mpe ng ev dence t av
he is now normotensive. ne ve the the . We n w have a eve sa agent
dab gat an but n t the the s (as Feb ua , 2016).
Question 2.3.6 I the patient desires cardioversion, the next The sh u d be ava ab e s n, th ugh. y u sh u d
step in the management o this patient is: av d ed xaban (Sava sa). The utc me data sn’t as
A) Start war arin. g d as w th the act Xa nh b t s.
B) Start heparin and rivaroxaban at the same time.
C) Start heparin.
D) Start aspirin. Question 2.3.8 All o the ollowing can be used to cardiovert
atrial brillation EXCEPT:
Answer 2.3.6 The correct answer is “A.”We may want to cardio- A) Ibutilide.
vert this patient in the uture. “A” is the most reasonable option B) Electrical cardioversion.
CHAPTER 2 • CAr Dio l o Gy 55

C) Quinidine. His atrial brillation has not been addressed since it was
D) Digoxin. picked up by the surgeon at a pre-op visit. His heart rate is
E) Procainamide. 80 bpm when you see him, his rhythm is irregularly irregular,
and he has no signs o heart ailure.
Answer 2.3.8 The correct answer is “D.” Digoxin does not
work to cardiovert atrial brillation. Digoxin may acilitate Question 2.4.1 Which o the ollowing options would be
cardioversion in patients with heart ailure by reducing atrial appropriate or this patient?
stretching. However, it does not convert atrial brillation. All A) Anticoagulate the patient with war arin and allow him to
o the other answers are correct. Because o potential induction stay in atrial brillation.
o arrhythmias with the other agents, electrical cardioversion B) Place the patient on aspirin and allow him to stay in atrial
is becoming the pre erred method o restoring normal sinus brillation.
rhythm. C) Give digoxin to cardiovert the patient.
D) Strongly suggest cardioversion to this patient since sus-
Objectives: Did you learn to . . .
tained normal sinus rhythm yields the best long-term
• r ec gn ze the c n ca and ECG p esentat n at a
b at n?
E) Add urosemide to prevent the development o heart ailure
• Use ate-c nt ng d ugs t t eat a pat ent w th at a
and edema.
b at n?
• App p ate emp ant c agu at n n at a b at n
Answer 2.4.1 The correct answer is “B.” T is patient’s CHA2-
a pat ent unde g ng ca d ve s n?
DS2-VASC (see able 2-6A) score is “1” allowing him to take
• ident app p ate s tuat ns ca d ve s n at a
aspirin rather than being ully anticoagulated with oral antico-
b at n?
agulants in the presurgical setting. A CHA2-DS2-VASC score o
“1” corresponds to what we used to call “lone atrial brillation.”
It is reasonable to allow the patient to remain in atrial bril-
lation, as long as they are rate-controlled with the knowledge
that antiplatelet agents alone or in combination are in erior to
A 70-year-old male complains o erectile dys unction and oral anticoagulants or stroke prophylaxis. Outcomes o patients
requests sildena l (Viagra) or erectile dys unction, which you who stay in atrial brillation and are given appropriate therapy
believe is secondary to vascular disease. are the same (or a bit better) than in patients in whom one tries
to maintain sinus rhythm with drugs such as amiodarone, etc.
Which o the ollowing antihypertensive drugs can cause T us, “D” is wrong.
prolonged hypotension when used with sildena l?
A) Peripheral alpha-blockers.
B) Calcium channel blockers (CCBs).
D) Diuretics. CHA2DS2-VASc SCORE
E) Beta-blockers.
Criteria Points

The correct answer is “A.” T e peripheral alpha-blockers C ngest ve Hea t Fa u e 1

(doxazosin, prazosin, and tamsulosin) can cause symptomatic H pe tens n (t eated 1
hypotension when combined with sildena l or other drugs o ab ve 140/90 mm Hg)
this class (Cialis [tadala l], Levitra [vardena l]). T is hypoten-
Age >75 2
sive e ect is more severe when these drugs are combined with
a nitrate. Nitrates should not be administered within 24 hours D abetes 1
(or longer in patients with renal or hepatic dys unction) o these
St ke, TiA 2 Score and Risk of CVA
drugs, as the combination has reportedly resulted in strokes.
th mb emb c d sease ( n %/ )
None o the other drugs (“B”–“E”) cause this hypotensive e ect
2 = 2.2%/
when combined with sildena l.
3 = 3.2%/
4 = 4%/
CASE 2.4 5 = 7%/
6 = 10%/
A 55-year-old male with a history o newly identi ed atrial
brillation is re erred to you or “medical clearance” or sur- Vascu a d sease (CAD, 1
PAD, a t c p aque)
gery. He has a history o hypertension and hypercholesterol-
emia (calculate his CHA2-DS2-VASC score, see able 2-6A). Age 65–74 1
He has normal cardiac unction otherwise with a normal
Sex Categ Fema e 1
ejection raction and no valvular disease on echocardiogram.
56 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW

TABLE 2-6B TREATMENT OF ATRIAL FIBRILLATION T e 75-year-old patient has his surgery and returns to your
BASED ON THE CHA2DS2-VASc SCORE clinic or a postoperative check-up 1 month a er his surgery.
CHA2DS2 VASc Score Recommended Treatment You check his INR and it is noted to be 5.2. T ere is no active
0–1 (ma e) Asp n 81–300 mg/da (0.5–0.7% bleeding.
st ke sk/ )
Question 2.4.3 The most appropriate action at this point
1 ( ema es) Asp n 81–300 mg/da (0.1–0.2%
is to:
st ke sk/ )
A) Hospitalize the patient or observation since he is at a high
(N te that w men aut mat ca have a
sc e 1 based n gende ) risk o bleeding.
B) Give the patient 5 mg o vitamin K orally.
2 g eate , ma e Ant c agu at n w th wa a n ( the C) Give the patient 2 units o resh rozen plasma to reverse his
ema e ant c agu ant)a
Xa e t ( va xaban), E qu s (ap xaban) and P adaxa (dab gat an).
D) Hold the next war arin dose and reduce the maintenance
E) A, B, and C.

HELPFUL TIP: Answer 2.4.3 The correct answer is “D.” T e risk o bleeding
H w sh u d u app the CHA2-DS2-VASC sk sc e t in a relatively healthy patient with an INR o 5.2 is very low.
the ap ? Check ut Tab e 2-6B. T us, simply holding the next one to two doses o war arin and
reducing the maintenance dose o war arin is appropriate. “A”
is incorrect because the patient does not need hospitalization.
T e patient returns at age 75. He is older. You, however, have “B” is incorrect because it will be di cult to reanticoagulate the
not aged a day because doctors are immortal, right? He is now patient a er vitamin K is administered. “C” is incorrect because
hypertensive, has diabetes, and he needs surgery to remove there is no active bleeding.
his gallbladder. His CHA2-DS2-VASC score is now 4 and he is
on anticoagulation war arin. T e patient misunderstands your instructions and takes an
extra dose o war arin that evening and or the next 2 days.
Question 2.4.2 Which o the ollowing approaches is the He returns to your clinic and his INR is now 13.
best or controlling his anticoagulation given that he needs
surgery? Question 2.4.4 What is the best option or therapy at this
A) Stop the war arin several days be ore surgery to allow his point?
INR to normalize. Restart the war arin a er surgery. A) Vitamin K 5 mg IV × 1.
B) Hospitalize the patient a couple o days ahead o time and B) Fresh rozen plasma.
start heparin. T en stop his war arin. Restart the war arin C) Vitamin K 5 mg PO × 1.
a er surgery. D) Vitamin K 10 mg IV × 1.
C) Use low-molecular weight heparin at home and stop the
war arin once this is started. Restart the war arin a er sur- Answer 2.4.4 The correct answer is “C.” Giving this patient
gery. 5 mg o PO vitamin K is the best solution. T is has been ound
D) Stop the war arin several days be ore surgery to allow his to reduce the INR while still allowing the patient to be anticoag-
INR to normalize. Start heparin a er surgery and simulta- ulated relatively easily a er treatment. “B” is incorrect because
neously restart war arin. there is no call or FFP in this asymptomatic patient. T e other
answers are incorrect because there is no advantage to higher
Answer 2.4.2 The correct answer is “A.” For patients with doses or IV doses o vitamin K in this patient, and the higher
nonvalvular atrial brillation who are undergoing surgery doses will make continued anticoagulation more di cult.
or invasive diagnostic procedures, it is reasonable to inter-
rupt anticoagulation or up to 1 week without substituting HELPFUL TIP: r EVEr SiNG WAr FAr iN
heparin (assuming they haven’t had a recent stroke or other in pat ents wh a e n t b eed ng:
thromboembolic event). “Bridge” therapy with IV heparin or • i the iNr s <4.5 s mp educe the d se wa a n
low-molecular weight heparin con ers no bene t (Circulation. h d the next d se wa a n.
2015;131(5):488). T e risk o perioperative bleeding with hepa- • i the iNr s 4.5 t 10 u have seve a pt ns. i the e
rin is actually greater than the risk o thromboembolism rom s n b eed ng: h d ne tw d ses wa a n.
atrial brillation. “B,” “C,” and “D” are incorrect because the r ut ne v tam n K s n t ec mmended. i the pat ent
patient does not need heparin. Bridging therapy is typically w equ e su ge s at h gh b eed ng sk, adm n-
indicated or patients at higher risk or thromboembolic events ste v tam n K ≤ 5 mg w th an the 1 t 1.5 mg n
such as those with mechanical heart valves, prior stroke, or 24 h u s.
CHA2DS2-VASc score >5.
CHAPTER 2 • CAr Dio l o Gy 57

B) Re er the patient to a cardiologist or an EP study to deter-

• i the iNr s >10 adm n ste 2.5 t 5 mg v tam n K mine the best drug to control this rhythm.
even the e s n b eed ng. C) Implant an automatic de brillator to prevent sudden death.
in pat ents wh a e b eed ng: D) Start a beta-blocker.
• Adm n ste p th mb n c mp ex c ncent ate (e.g. E) Order transthoracic echocardiogram to rule out structural
Kcent a . . . sh u d the bu a v we ? The can a d t!). heart disease.
Th s s p e e ed ve esh zen p asma, wh ch s sec-
nd ne. in add t n, adm n ste 5 t 10 mg v tam n K. Answer 2.5.2 The correct answer is “E.” Nonsustained ventric-
See A g thm m P esc be ’s l ette ava ab e at: http:// ular tachycardia may have an adverse prognosis in the presence
pha mac sts ette .the apeut c esea ch.c m/p /A t c eDD. o structural heart disease such as hypertrophic cardiomyopathy
aspx?n dchk=1&cs=&s=Pl &pt=2& pt=2&dd=280509 or ischemic heart disease. An echocardiogram as well as stress
test may be help ul in ruling them out. T ere is no evidence that
nonsustained, asymptomatic ventricular tachycardia worsens
Objectives: Did you learn to . . . outcomes as long as the patient has no underlying cardiac
• We gh the advantages and d sadvantages ate c nt disease. In an otherwise healthy, asymptomatic patient, the risk
ve sus h thm c nt st ateg es at a b at n? o trying to use antiarrhythmic drugs to suppress ventricular
• Manage ant c agu at n and at a b at n v s-à-v s ectopy leads to worse outcomes than doing nothing. Quinidine,
su ge ? mexiletine, amiodarone, and other antiarrhythmics all have
• Manage the ve -ant c agu ated pat ent? proarrhythmic e ects. In general, there is more sudden death in
these patients i they are treated with antiarrhythmic drugs than
CASE 2.5 i they are watched. T ere ore, “A” is incorrect because these
drugs will actually increase mortality. “B” is incorrect since the
A 62-year-old emale presents to your o ce with a history o patient has asymptomatic, sel -limited episodes. T e reason to
occasional palpitations that are o great concern to her. She do an EP study is to see i there is an inducible arrhythmia and
notes that she eels a racing heart that lasts or a matter o sec- to determine treatment. T is patient does not need treatment.
onds and occurs every 7 days or so. However, when she has the “C” is incorrect because this patient has asymptomatic nonsus-
symptoms, she will generally get our to ve episodes during tained ventricular tachycardia. T us, an implantable de bril-
that day. She denies any chest pain, dyspnea, lightheadedness, lator is not indicated. A er your evaluation is complete, you
or other associated symptoms. You order an event monitor may prescribe a beta-blocker (“D”) or symptomatic relie . T is
and it shows that the patient is having nonsustained episodes patient is overall asymptomatic so this would not be the best
o monomorphic ventricular tachycardia lasting 4 beats or less option at this time.
T e echocardiogram is normal, and the patient does well or
Question 2.5.1 The best approach at this point is to: the next 3 months but then becomes symptomatic with pro-
A) Start an antiarrhythmic such as quinidine or mexiletine to longed episodes o ventricular tachycardia. While all o the
control the heart rhythm. episodes are sel -limited, the patient has had two episodes o
B) Re er the patient to a cardiologist or an EP study to deter- syncope.
mine the best drug to control this rhythm.
C) Implant an automatic de brillator to prevent sudden death. Question 2.5.3 Which o the ollowing is the next best step
D) Implant a pacemaker. in treating this patient?
E) Check serum potassium, magnesium, SH. A) Sotalol.
B) Implantable de brillator.
Answer 2.5.1 The correct answer is “E.” T e rst step in deter- C) Amiodarone.
mining the treatment o this patient is to make sure that there is D) Electrophysiologic study.
not an underlying metabolic abnormality that could predispose E) ocainide (an oral lidocaine equivalent).
to this rhythm abnormality.
Answer 2.5.3 The correct answer is “D.” An electrophysiologic
You check a panel o laboratory studies including thyroid study is indicated to induce and characterize the ventricular
unction tests, electrolytes, magnesium, glucose, and CBC. tachycardia. Certain types o ventricular tachycardia respond
T ey are all within normal limits. You suggest that the very well to radio requency ablation. Some o you may have
patient avoid potential triggers such as caf eine and sympa- answered “B.” T is is true in patients with ischemic heart
thomimetics. “Darn,” she sighs. “I have to quit my crystal disease, le ventricular dys unction and symptomatic ven-
meth?” tricular tachycardia. T ese patients should get an implant-
able de brillator as should “all” heart ailure patients with an
Question 2.5.2 The next step or this patient is to: ejection raction o <30% to 35% (there are literally over 200
A) Start an antiarrhythmic such as quinidine or mexiletine to variations o this based on heart ailure class, QRS duration, etc.,
control the heart rhythm. but this is the basic idea).
58 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW

Objectives: Did you learn to . . . the Framingham study showed that the symptoms blamed on
• Eva uate a pat ent w th pa p tat ns? mitral valve prolapse (anxiety, PACs, tachycardia, etc.) are no
• Manage n nsusta ned, as mpt mat c, vent cu a more prevalent in those with mitral valve prolapse than in those
tach ca d a? without it. “C” is incorrect. A bicuspid aortic valve may cause
PACs as a result o heart ailure when the patient decompensates
CASE 2.6 and has increased le -sided heart pressures. However, a bicus-
pid aortic valve itsel is not a source o PACs. Similarly, hyper-
A 22-year-old emale presents to your o ce with a history o trophic cardiomyopathy, other causes o heart ailure, drugs
palpitations. You are able to capture the arrhythmia on the (e.g., theophylline and digoxin), and neurologic diseases can be
monitor in your o ce: the rhythm strip shows evidence o associated with PACs.
isolated premature atrial contractions (PACs). She is other-
wise healthy and taking no medications, and there is no am- T is patient is bothered by her PACs. She is rather aware o
ily history o heart disease. them and nds them disconcerting.

Question 2.6.1 All o the ollowing are salient points o the Question 2.6.3 What is the best pharmacologic therapy to
history with regard to PACs EXCEPT: consider at this point?
A) Aged cheese consumption. A) Sotalol.
B) Ca eine use. B) Metoprolol.
C) obacco use. C) rasylol.
D) Alcohol use. D) Amiodarone.
E) COPD. E) Mountain Dew—lots o it.

Answer 2.6.1 The correct answer is “A.” Aged cheese can cause Answer 2.6.3 The correct answer is “B.” A beta-blocker may
problems in combination with monoamine oxidase inhibitors help to reduce this patient’s PACs. “A” is incorrect because,
(MAOIs). In combination with an MAOI, aged cheese and while sotalol can be used or both atrial and ventricular
other sources o tyramine can cause a hypertensive emergency. arrhythmias, it is proarrhythmic and can cause torsades de
However, this patient is not taking any medications. All o the pointes. T us, it should be initiated in the hospital with moni-
other conditions and drugs listed can cause PACs. While there toring and reserved or those with severe arrhythmias. “C” is
are conf icting data about the strength o the association ca - incorrect because rasylol is the trade name or aprotinin, an
eine, it is clear that COPD, tobacco, and alcohol can all cause enzyme that is used to reduce bleeding during surgical pro-
an increase in sympathetic tone, leading to PACs. Neurologic cedures. “D” is incorrect because, like sotalol, amiodarone is
abnormalities (e.g., stroke) can also be associated with PACs, as proarrhythmic, and its use should be limited to those with sig-
can some drugs (e.g., theophylline). ni cant arrhythmias.
Objectives: Did you learn to . . .
HELPFUL TIP: • r ec gn ze causes PACs?
y u have t eat 2 p unds chedda cheese n ha an • T eat a pat ent w th b the s me PACs?
h u n de t deve p a h pe tens ve c s s w th an
MAo i. in stud es whe e the e was ee access t cheese,
the max mum an ne was ab e t eat was 1.9 p unds n QUICK QUIZ: VAl VUl Ar DiSEASE
2 h u s. Be eve t n t, s me ne stud ed th s (p b-
ab s mewhe e n W sc ns n).
Surgery is indicated in which o these patients with valvular
Question 2.6.2 Which o the ollowing statements about A) An asymptomatic patient with severe mitral regurgitation
PACs is true? and a le ventricular ejection raction (LVEF) o less than
A) Mitral valve prolapse is associated with PACs. 60%.
B) Mitral valve stenosis is associated with PACs. B) An asymptomatic patient with a bicuspid aortic valve.
C) Bicuspid aortic valve is associated with PACs. C) Asymptomatic aortic regurgitation with an LVEF o less
D) None o the above is true. than 50% on echocardiogram.
D) Only symptomatic valvular lesions should be approached
Answer 2.6.2 The correct answer is “B.” Anything that can surgically.
cause an increase in le atrial pressures (and there ore atrial E) A and C.
wall stretching) is associated with an increase in the number
o PACs. Mitral stenosis causes increased pressures in the le The correct answer is “E.” Once patients with mitral regur-
atrium, wall stretching, and enlargement and thus predisposes gitation and aortic regurgitation become symptomatic,
to PACs. “A” is incorrect. Even though multiple problems have the morbidity and mortality increases signi cantly. T us,
been blamed on mitral valve prolapse, a study done as part o these patients should be operated on be ore they become
CHAPTER 2 • CAr Dio l o Gy 59

symptomatic. Patients should have routine echocardiogra-

phy yearly i they have severe valvular disease. In addition to You decide that this patient may have heart ailure. An ECG
evaluating the valve, echocardiography allows you to evalu- shows no evidence o prior or ongoing ischemia. T ere are no
ate ventricular size and unction. Importantly, proper man- signs o atrial enlargement or ventricular hypertrophy.
agement o patients with valvular heart disease depends on
accurate diagnosis o the cause as well as proper staging o the Question 2.7.2 The proper conclusion rom this is:
disease process, which is based on valvular anatomy, valvular A) he patient does not have cardiac chamber enlargement
hemodynamics, severity o le ventricular dilation and sys- or hypertrophy and there ore is unlikely to have heart
tolic unction, and patient symptoms. (NO E: le ventricular ailure.
systolic unction and patient symptoms are only part o the B) T e absence o evidence or prior in arct makes heart ailure
decision making process regarding management and timing unlikely.
o re erral to surgery). C) Regardless o the ECG results, clinical judgment alone is su -
cient to make the diagnosis o heart ailure, being correct
85% o the time.
CASE 2.7 D) T e patient’s edema is likely rom venous insu ciency.
A 74-year-old male presents to your o ce with a chie E) Despite a normal ECG, urther testing is needed in this
complaint o a “long cold” with an intermittent cough or patient to evaluate or heart ailure.
5 months. He has also noticed that he gets up to urinate twice
a night although he has no trouble with his urine stream, Answer 2.7.2 The correct answer is “E.” “A” is not correct
starting urination, or dribbling a erward. He has been a bit because only 30% to 60% o moderate-to-severe le ventricu-
more tired lately and notices that his exercise tolerance has lar hypertrophy (LVH) is detectible on ECG. “B” is incorrect
decreased to several blocks, limited mainly by shortness o because patients with diastolic dys unction (discussed later)
breath. He has not had any chest pain. He has no history o may not have any evidence o prior ischemia or MI. “C” is
asthma or COPD and has not had any exposures to drugs or incorrect. T e clinical diagnosis o heart ailure is incorrect up
chemicals. He has a history o hypertension and noncompli- to 50% o the time. For this reason, con rmation is required
ance with medical recommendations. In act, he is taking no be ore embarking upon a therapeutic adventure or heart ail-
medications except or an aspirin a day. His pulse is 100 bpm ure. “D” is unlikely, since the patient has other symptoms o
with a blood pressure o 160/95 mm Hg. He looks pretty well. heart ailure (exertional dyspnea, cough, etc.) that make simple
On examination, you nd only trace pitting edema o the venous insu ciency unlikely.
lower extremities.
Question 2.7.3 You decide on urther testing. Assuming
Question 2.7.1 Which o the ollowing is NOT a possible every test is easily available to you (which might not be the
cause o cough in this patient? case depending on the setting in which you work), what is
A) Heart ailure. the one best test that you would use to determine i this
B) Asthma. patient has heart ailure?
C) Deconditioning. A) Echocardiography.
D) COPD. B) Brain natriuretic peptide (BNP) level.
E) GERD. C) Chest radiograph looking or evidence o pulmonary edema
(Kerley B lines, etc.).
Answer 2.7.1 The correct answer is “C.” Deconditioning D) SPEC thallium test.
may cause dyspnea on exertion but should not cause a cough. E) Positron emission tomography (PE ) testing.
T e purpose o this question is to point out the act that a
“chronic cold” or “chronic cough” in an elderly person can Answer 2.7.3 The correct answer is “A.” Echocardiography is
be due to a myriad o causes, including “occult” heart ailure the procedure o choice or the diagnosis o heart ailure. T is
(systolic or diastolic HF). Do not make the assumption that is or two reasons. First, you can assess le ventricular systolic
the patient’s diagnosis (e.g., a “chronic cold”) is necessarily unction as well as look or diastolic dys unction to determine
the correct diagnosis. i this is systolic or diastolic heart ailure (i.e. heart ailure with
reduced ejection raction, HFrEF or heart ailure with preserved
ejection raction, HFpEF respectively). Second, you can evalu-
ate the potential causes o heart ailure including valvular heart
S st c hea t a u e (sec nda t n a ct n, etc.)
disease, ischemic heart disease, pericardial disease, deposition
s n w te med “Hea t Fa u e w th a educed Ejec-
disease (amyloidosis, hemochromatosis) etc. “B” is incorrect
t n F act n” (HF EV). D ast c hea t a u e s n w
because the BNP will give you less concrete in ormation about
te med “Hea t Fa u e w th a p ese ved Eject n F ac-
the patient versus echocardiography. In this patient, with a high
t n (HFpEF). in th s b k we use b th the “ d” and
pretest probability o heart ailure, BNP will most likely be ele-
new n tat ns.
vated. “D” and “E” are incorrect because SPEC thallium and
PE testing are best used to diagnose ischemia due CAD.
60 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW


in a w- sk pat ent, a BNP <100 pg / ml e ect ve T x ns such as methamphetam ne, c ca ne, a c h ,
u es ut hea t a u e. A BNP 100 t 500 pg/ml s n- and ant ne p ast c chem the apeut c d ugs can cause
dete m nate and ma n t be e ated t ca d ac d sease. a ca d m path and sh u d be c ns de ed as a p s-
A BNP >500 pg/ml s e at ve spec c hea t a - s b e et g CHF n the app p ate pat ent.
u e ( the ca d ac and n nca d ac causes a e exc ud-
ed). A te nate ca d ac causes nc ude ACSs, hea t musc e Question 2.7.5 Which o the ollowing is the most appro
d sease, va vu a hea t d sease, pe ca d a d sease, at a priate next strategy to work up this patient’s systolic heart
b at n, m ca d t s, ca d ac su ge , and status-p st ailure (HFrEF)?
DC ca d ve s n. A) Cardiac MRI to assess myocardial viability.
B) Coronary angiogram.
C) Measure serial troponins to rule out ACS.
(LESS) HELPFUL TIP: D) Electrophysiologic study to assess or inducible ventricular
N nca d ac causes an e evated BNP nc ude ena a - arrhythmia.
u e, anem a, advanced age, seps s/ Sir S, pu m na ( b- E) C to assess calcium scores.
st uct ve s eep apnea, pu m na h pe tens n, seve e
pneum n a), c t ca ness, seve e bu ns, t x cmetab - Answer 2.7.5 The correct answer is “B.” Ischemic heart disease
c events (cance , chem the ap , enven mat n). o be- is the most common etiology or heart ailure associated with
s t can cause a a se w BNP. BNP-d ected the ap systolic dys unction. I you can reverse the ischemia, mortal-
may be use u n s me pat ents. H weve , m st data at ity is decreased rom 16% annually to 3.2% annually. O all the
th s p nt suggests that t eat ng based n s mpt ms options listed above, coronary angiography remains the gold
and t eat ng based n BNP have s m a utc mes (Eu standard to evaluate or CAD in this setting. Coronary angio-
Hea t J. 2014;35(1):16–24). grams provide in ormation about anatomy and easibility o
revascularization but do not predict recovery o unction. T is
patient does not have chest pain or ECG changes to suggest
acute cardiac syndrome (ACS); there ore, “C” is incorrect. “D”
T e patient has an echocardiogram that shows a le ven- is incorrect, as there is no indication or an electrophysiologic
tricular ejection racture (LVEF) o 35% and a regional wall study in the absence o any arrhythmia. “E” is incorrect as the
motion abnormality (RWMA). presence or absence o coronary calci cation would not change
the overall management plan or this patient. C calcium scor-
Question 2.7.4 This is the most consistent with a diagnosis ing may be used as an additional risk strati cation tool in inter-
o : mediate-risk patients (similar to CRP, in addition to traditional
A) Systolic heart ailure secondary to myocarditis. risk actors such as hypertension, dyslipidemia, vascular or
B) Systolic heart ailure secondary to CAD. renal disease, etc.) but not in high-risk, symptomatic patients.
C) Diastolic heart ailure.
D) Systolic heart ailure secondary to constrictive pericarditis. T e coronary angiogram shows dif use CAD; no coronary
E) Age-related changes; there ore, a normal variant. lesions are considered to be amenable to angioplasty and
there are no vessels considered to be viable targets or bypass
Answer 2.7.4 The correct answer is “B.” A regional wall surgery. You decide to initiate medical therapy in this patient.
motion abnormality (RWMA) suggests that this patient has In addition, you advise the patient regarding the nonphar-
ischemic or in arcted myocardium. “A” is not the best choice macologic therapies or heart ailure treatment.
since those with myocarditis ( ulminant or acute) typically
have global hypokinesis (although RWMA has been reported) Question 2.7.6 Nonpharmacologic therapies or systolic
and the patient would typically appear more clinically ill. “C” heart ailure (HFrEF) include all o the ollowing EXCEPT:
is incorrect by de nition. Diastolic heart ailure (HFpEF) A) Fluid restriction o <2 L/day.
requires a LVEF o at least 50%, recognizing that this group B) Sodium restriction o <2 g/day.
may not have an entirely normal LVEF, but the major abnor- C) Dietary consultation.
mality is not a reduction in LV systolic unction. Systolic heart D) Cardiac risk actor modi cation.
ailure (HFrEF) is de ned by an LVEF o <40%. Diastolic heart E) Monthly weight monitoring.
ailure (HFpEF) is associated with a hypertrophied le ven-
tricle and a preserved LVEF. T e echocardiogram in constric- Answer 2.7.6 The correct answer is “E.” Prior to initiation o
tive pericarditis (“D”) generally shows normal le ventricular therapy, it is important to determine the patients NYHA classi-
systolic unction. It may reveal pericardial thickening, dilated cation and ACC/AHA stage o HF, which in orms the clinician
in erior vena cava or hepatic veins, and abnormal mitral and regarding guideline-directed medical therapy. T e keystone o
tricuspid in-f ow Doppler. an e ective heart ailure treatment regimen is sodium and f uid
CHAPTER 2 • CAr Dio l o Gy 61

balance as well as management o comorbidities. Frequently over- All o the others options, including the combination o iso-
looked, these are the most common causes o heart ailure exac- sorbide dinitrate and hydralazine, have been shown to reduce
erbation. It is imperative to get a dietary consultation or every mortality. However, hydralazine and isosorbide dinitrate are
patient with newly diagnosed heart ailure. Cardiac risk actors, generally reserved or those patients who are unable to toler-
including: hypertension, diabetes, hyperlipidemia, sleep apnea, ate ACE inhibitors or angiotensin receptor blockers (ARBs) or
obesity, sedentary li estyle, smoking/alcohol/drug use, need to be remain symptomatic despite maximal medical therapy with the
treated with the same aggressiveness as in a patient with an ACS. other medications, especially in A rican Americans. Enalapril
Patient should be advised about daily weight monitoring rather reduces mortality by 28% when compared with hydralazine and
than monthly monitoring. A weight gain o more than 3 to 5 lb nitrates. T us, hydralazine and nitrates are second line. None o
may necessitate additional doses o a diuretic. NO E: signi cant the “traditional” loop diuretics such as urosemide, bumetanide,
f uid restriction to 1.5 to 2.0 L/day is typically, though not exclu- etc., have been shown to positively a ect mortality.
sively, reserved or Stage D advanced HF patients who are hypo-
natremic or diuretic resistant. Both sodium and f uid balance You start this patient on urosemide or diuresis and lisinopril
recommendations are best implemented in the context o a struc- or HFrEF. You also decide to initiate metoprolol succinate or
tured daily weight and symptom sel -monitoring home program. its survival bene ts. However, the patient’s symptoms worsen.

You wish to start an appropriate drug regimen or this patient’s Question 2.7.8 Which o these is true about the use o
heart ailure. metoprolol in HFrEF?
A) It is the only beta-blocker indicated or use in HFrEF.
Question 2.7.7 All o the drugs below have been shown B) Its best use is in those patients who are still symptomatic
to reduce mortality in patients with systolic heart ailure since it will help to control symptoms.
(HFrEF) EXCEPT: C) It should only be initiated in patients with well-controlled
A) Digoxin. HFrEF who are not currently having signi cant symptoms
B) Metoprolol succinate. (i.e., decompensated).
C) ACE inhibitors. D) Beta-blockers can lead to signi cant hypokalemia when
D) Hydralazine and long-acting nitrates used in combination in combined with diuretics, so potassium levels should be
patients intolerant o ACE inhibitors. monitored closely.
E) Spironolactone. E) Beta-blockers are contraindicated in patients who have a
combination o COPD and HFrEF.
Answer 2.7.7 The correct answer is “A.” Digoxin is an inotro-
pic agent, and as such, would intuitively make sense as an e ec- Answer 2.7.8 The correct answer is “C.” Beta-blockers should
tive drug or HFrEF. However, digoxin has not been shown to not be initiated in patients who are signi cantly symptomatic
increase survival and in act may worsen outcomes, especially or decompensated. While beta-blockers do reduce mortality,
in women. Its use is primarily or symptomatic relie . I using they can increase symptoms and urther exacerbate heart ail-
digoxin in HFrEF, the therapeutic target is a dose that achieves ure. T ere ore, they are best initiated in the stable patient (as
a plasma concentration o drug in the range o 0.5 to 0.9 ng/mL. an outpatient or 24 to 48 hours prior to hospital discharge and
T e common daily dosage to achieve that target is typically on a stable drug regimen). Even then some patients cannot tol-
0.125 to 0.25 mg/day in patients <70 years o age with normal erate the introduction o beta-blockers without worsening o
renal unction and body mass. For patients with abnormal symptoms, which may require additional diuresis, discontinua-
renal unction, low body mass or age >70, low doses (0.125 mg tion o the beta-blocker, a reduction in dose, or other measures.
daily or every other day) are recommended initially, and the “A” is incorrect. Other beta-blockers have been used in HFrEF,
dose then titrated to the target therapeutic range. Digoxin including carvedilol. “B” is incorrect because beta-blockers may
does reduce hospitalizations and improve symptoms in those actually worsen heart ailure symptoms. “D” is incorrect since
with HFrEF who are symptomatic despite use o other maxi- beta-blockers do not cause hypokalemia. “E” is incorrect. Beta-
mal guideline directed therapy. Digoxin may also be utilized blockers can be used in patients with COPD with the same cave-
in addition to beta-blockers or controlling the ventricular ats that apply to any other patient: i the patient is becoming more
response in HFrEF patients with atrial brillation (though symptomatic on the beta-blocker, reduce the dose or discontinue
it is generally not very e ective in ambulatory patients). It is the drug. In act, beta-blockers may improve survival in COPD
ine ective at treating atrial brillation in those with a nor- (BMJ. 2011;342:d2549; BMC Pulmonary Medicine. 2012;12:48).
mal EF. Avoid digoxin in patients with signi cant sinus or AV
nodal block unless they have a pacemaker. NO E: Other car- HELPFUL TIP:
diac medications such as amiodarone, dronedarone, verapamil, When sta t ng a beta-b cke HF EF, sta t w and
propa enone and quinidine as well as noncardiac meds such as g s w! When sta t ng d g x n HF EF, m n t
clarithromycin, erythromycin, itraconazole and cyclosporine h p ka em a, h p magnesem a, h p th d sm t
can increase the serum digoxin concentrations and may pre- av d d g x n t x c t , even w th w d ses.
cipitate digoxin toxicity.
62 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW

consumption and f uid retention), increased metabolic demand

You reduce the dose o metoprolol succinate and consider (e.g., rom in ection), anemia, medication noncompliance,
starting this patient on another medication. arrhythmia, and ischemia. T e inappropriate use o medica-
tions, such as some calcium channel blocker and the institution
Question 2.7.9 Which o the ollowing patients is/are good o beta-blockers when CHF is decompensated, are also com-
candidates or spironolactone? mon causes o exacerbations o HF.
A) A patient with NYHA Class I and Class II heart ailure.
B) A patient with NYHA Class III and Class IV heart ailure. T e patient notes that he did have some chest pain earlier in
C) Both A and B. the day. You want to initiate therapy. You take his vitals, and
D) Neither A nor B. his pulse is 100 bpm, blood pressure 140/95 mm Hg, oxygen
saturation 89%on room air, and respiratory rate 32.
Answer 2.7.9 The correct answer is “B.” Spironolactone has
been shown to reduce mortality in patients with New York Heart Question 2.7.11 Besides oxygen, the one best drug to initi
Association (NYHA) Class III and Class IV heart ailure. It has ate rst in the ED to treat this patient with an acute exacer
not been studied in Class I (thus “A” is wrong), However, it may bation o his chronic HFrEF is:
be use ul in symptomatic patients with Class II with an EF o A) Furosemide.
<30%. Serum potassium needs to be monitored closely a er ini- B) Digoxin.
tiation o spironolactone, especially since it will generally be used C) A positive inotrope, such as dobutamine.
with an ACE inhibitor or ARB, both o which can increase the D) Nitroglycerin.
serum potassium. T is drug should be avoided in patients with E) An ACE inhibitor
renal insu ciency or patients with serum potassium >5 mEq/L.
Spironolactone is indicated or patients with NYHA Classes II– Answer 2.7.11 The correct answer is “D.” T is patient will ben-
IV and who have LVEF ≤ 35% and a creatinine o <2.5 mg/dL e t rom nitroglycerin or several reasons. First, the patient has
in males or <2.0 mg/dL in emales (or estimated GFR >30 mL/ told you that he had chest pain earlier today. T us, it is possible
min/1.73 m 2). Eplerenone is another aldosterone inhibitor but is that this patient’s HF exacerbation is due to ischemic disease.
much more expensive with little, i any, advantage. Nitroglycerin will help this via vasodilation. T e second rea-
son is that the goal here is to restore normal cardiac unction
HELPFUL TIP: by causing vasodilation and decreasing preload and a erload.
A sk en (Tektu na), a en n nh b t , is contraindicat- Nitroglycerin will do both o these. “A,” urosemide, is also a
ed w th an Ar B ACE nh b t . it w sens utc mes good choice but not the one best choice. By inducing diuresis,
and causes h pe ka em a. it a s w sens utc mes urosemide will also signi cantly decrease preload and provide
n pat ents w th d abetes. it d esn’t ea have a we - symptomatic relie . But remember not all HF patients are f uid-
de ned p ace n the ap . overloaded (such as with f ash edema rom ischemia). “B” is
incorrect because it will take some time or digoxin to have a
signi cant impact on this patient’s symptoms. “C” is incorrect
You treat this patient with metoprolol succinate, lisinopril, because dobutamine is a second-line drug reserved or those
urosemide, and aspirin. T is regimen seems to help, and the not responding to more conservative therapy and it would not
patient’s symptoms improve. However, a ew weeks later, he be indicated in active ischemia due to increasing myocardial
presents to the ED with increased dyspnea. T ere have been oxygen demand. “E” is technically not incorrect, but it is not
no changes in his medications, and he assures you that he is the best answer. T ere is ample evidence that ACE inhibitors,
taking his medications as directed. His examination reveals which work as a erload reducers, can be used in acute HF exac-
that he has elevated JVD, rales over the lower hal o his lung erbations either IV (e.g., enalaprilat) or sublingual (e.g., capto-
elds bilaterally, and pedal edema. pril). However, these drugs should be reserved as second-line
therapy or patients who do not respond to more appropriate
Question 2.7.10 Common causes o decompensation in initial measures, and they would not be the rst line to address
patients with otherwise stable heart ailure include all o ischemia among choices listed.
the ollowing EXCEPT:
A) Inactivity. You treat the patient with nitroglycerin, he improves, and
B) Fever. you admit him to the oor. While in the hospital, the patient
C) Arrhythmia. develops some additional chest pain that lasts or 10 min-
D) Dietary indiscretion. utes and responds to additional sublingual nitroglycerin. His
E) Ischemia. BNP is noted to be elevated. His hemoglobin (Hb) is 7.2 g/dL
and hematocrit (HC ) is 22%. He is still in congestive ail-
Answer 2.7.10 The correct answer is “A.” Inactivity will ure. T e pathologist tells you that there is blood available in
not generally cause an exacerbation o HF. T e major causes the blood bank to trans use this gentleman i you so choose.
o increased HF include dietary indiscretion (increased salt T ere is a problem, o course: he is in HF and now is some-
intake—“Say, can you pass the potato chips?”—increased f uid what tachycardic at 110.
CHAPTER 2 • CAr Dio l o Gy 63

Question 2.7.12 You tell the pathologist that: nh b t s, Ar Bs, d g x n, and sp n act ne n the t eat-
A) T e Hb o 7.2 g/dL is not an indication or trans usion. ment HF EF?
B) rans using this gentleman is inappropriate since he is • Desc be the e BNP measu ement n the eva uat n
already in HF and may become more f uid-overloaded with hea t a u e w th educed eject n act n and nes t de
a blood trans usion. n the t eatment hea t a u e?
C) You would like to go ahead with trans using this patient.
D) Making this patient’s blood more viscous with a trans usion
will increase the stress on his heart. CASE 2.8
E) Erythropoiesis-stimulating agents (ESAs), such as darbe-
Your patient with heart ailure does well and is discharged
poetin (Aranesp), are sa er and more e ective than blood
rom the hospital a er a couple o days. You are just beginning
trans usions or patients with HF.
to think that the authors are tired o writing questions about
heart ailure . . . but you are wrong. T e patient’s 70-year-old
Answer 2.7.12 The correct answer is “C.” T is patient should wi e shows up with shortness o breath. Her physical exami-
be trans used. Guidelines suggest triggering trans usion in heart nation is consistent with heart ailure. Since you have learned
disease when the Hb is <8 g/dL and i the patient is symptomatic so much rom this case already, you send her to get an echo-
(i.e., tachycardic, chest pain). T ere is no bene t to trans using cardiogram. You also order the recommended tests: CBC,
patient with a higher Hb (Ann Intern Med. 2013;159:770). Use electrolytes, ECG, thyroid unctions, etc.
clinical judgment o course, as there are no guidelines or trans-
usion in an individual with ACS. ESAs (“E”) seems to increase Question 2.8.1 The results o the echocardiogram show a
thromboembolic events without providing any bene t in those concentric thickening o the le t ventricle with an ejection
with stable HF and mild to moderate anemia. T ey should gen- raction o 75%. This is most consistent with:
erally be avoided in this population. A) Ischemic cardiomyopathy.
T ere are no o cial ACC/AHA recommendations regarding B) Diastolic dys unction (HFpEF).
trans usion. However, the mortality at 30 days is increased i the C) Viral cardiomyopathy.
Hb is <11 mg/dL in a patient with a non-S EMI. Whether or D) Hypertrophic cardiomyopathy.
not trans usion will help this is not known: it may just be that E) None o the above.
patients with anemia are sicker at baseline. Patients with an HC
o <20% to 24% likely bene t rom a trans usion while those
Answer 2.8.1 The correct answer is “B.” “A” is incorrect since
with an HC > 27% to 30% do not. For 25% to 26% use your
there would likely be evidence o RWMA i there had been an
judgment. HF is di erent. Blood trans usion should be reserved
old myocardial in arction. Also, this patient has a preserved
or patients with heart ailure that are severely anemic and the
ejection raction, which is consistent with diastolic dys unc-
trans usion be undertaken slowly and with the concurrent use
tion (HFpEF) rather than the decreased ejection raction
o diuretics to avoid volume overload (Am Heart J. 2009;158:
associated with ischemic cardiomyopathy. “C” is incorrect.
653–658). “A” and “B” are incorrect because this patient should
Viral cardiomyopathy is associated with a dilated ventricle
be trans used care ully as noted above. “D” is incorrect since
rather than a hypertrophic one, and there would be global
trans using this patient to a normal Hb and HC will not cause
dyskinesia with decreased ejection raction. “D” is incor-
excess blood viscosity.
rect; hypertrophic cardiomyopathy is usually associated with
asymmetric hypertrophy, o en septal, rather than concentric
hypertrophy o the le ventricle. Hypertrophic cardiomyopa-
HELPFUL TIP: thy may lead to HFpEF in addition to le ventricular outf ow
Nes t de (Nat ec ), a BNP ana g, can be used tract obstruction.
HF EF but s expens ve, c nt butes t ena a u e, and
ke nc eases m ta t . Nes t de can p duce p -
Question 2.8.2 Diastolic dys unction (HFpEF) is associated
nged h p tens n, wh ch m ts the d se that can be
with which o the ollowing?
used. Th s s a the ap ast es t . . . and that ma be
A) A prolonged history o untreated hypertension.
t cha tab e. Just d n’t use t.
B) Poor relaxation o the ventricular wall.
C) T yroid disease.
D) A and B.
Objectives: Did you learn to . . . E) B and C.
• r ec gn ze at p ca p esentat ns hea t a u e w th e-
duced eject n act n n the e de ? Answer 2.8.2 The correct answer is “D.” HFpEF is o en associ-
• Desc be the sens t v t and spec c t an ECG l VH? ated with long-standing hypertension as well as a sti ventricu-
• Eva uate a pat ent w th hea t a u e w th educed eject n lar wall that does not relax to allow good lling during diastole
act n? (there ore “diastolic dys unction”). “C” is not correct because
• Manage a pat ent w th hea t a u e w th educed eject n hyper- and hypothyroidism are usually associated with a dilated
act n and unde stand the e beta-b cke s, ACE cardiomyopathy.
64 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW

Question 2.8.3 HFpEF represents approximately what

percentage o HF?
Hea t a u e s a te m na ness w th a 5- ea su v va
A) <5%.
n 50%. Th s s w se than man cance s.
B) Approximately 10%.
C) Approximately 25%.
D) Approximately 50%. Objectives: Did you learn to . . .
E) >75%. • Unde stand the path ph s g HFpEF d ast c?
• T eat a pat ent w th HFpEF?
Answer 2.8.3 The correct answer is “D.” HFpEF represents
between 40% and 60% o cases o HF when looking at the
population as a whole. T e other answers are incorrect. T e CASE 2.9
point here is that, as discussed earlier, patients with HF need
an echocardiogram to determine what type o heart ailure Your “congestive heart ailure couple,” as they now call them-
they have. selves, are doing so well that the wi e re ers her cousin to
you (we still aren’t tired o writing heart ailure questions).
Her cousin, a 65-year-old male, arrives at your o ce and
HELPFUL TIP: you immediately notice the smell o tobacco leaching rom
HFpEF ccu s m e c mm n n e de p pu at ns. his clothing. T e small burns in his clothing con rm to you
that he smokes, and he in orms you that he has smoked
three packs per day “since birth.” He recently has noticed
some swelling in his eet and increased shortness o breath.
Question 2.8.4 Which o the ollowing drugs is the LEAST He denies a history o cardiac disease. An ECG per ormed
desirable in patients with HFpEF? in the o ce shows right axis deviation and a right bundle
A) Diuretics. branch block (RBBB). An echocardiogram shows that he has
B) ACE inhibitors. normal le ventricular unction but a hypertrophied right
C) Nitrates. heart with paradoxical bulging o the ventricular septum
D) Digoxin. into the le ventricle was noted.
E) Negative inotropes such as beta-blockers and CCBs.
Question 2.9.1 This clinical picture is most consistent with
Answer 2.8.4 The correct answer is “D.” Digoxin and other which o the ollowing?
positive inotropes (e.g., milrinone) are not very use ul in dia- A) Constrictive pericarditis.
stolic dys unction. T is makes sense. T e problem here is not a B) Chronic mitral valve prolapse.
lack o contractility but alternatively a lack o muscle relaxation. C) Cor pulmonale.
While there has not been a superior therapeutic regimen identi- D) Old right ventricular in arction with subsequent dys unction.
ed by randomized control trials, the goals o therapy are blood E) Chiari network.
pressure control, the use o diuretics to relieve congestion and
edema, treatment o ischemia i present, and control o the heart Answer 2.9.1 The correct answer is “C.” A typical picture o
rate to avoid tachycardia. cor pulmonale is right ventricular hypertrophy (RVH) with
paradoxical bulging o the septum into the le ventricle, right
Question 2.8.5 Which o the ollowing drugs or drug classes axis deviation on ECG, and partial or complete RBBB. “A” is
is theoretically the best choice or the treatment o HFpEF? incorrect. Constrictive pericarditis is associated with pericar-
A) ACE inhibitors. dial thickening, dilated in erior vena cava or hepatic veins, and
B) Beta-blockers. abnormal mitral and tricuspid f ow. “B” is incorrect because
C) Diuretics. mitral valve prolapse in the absence o severe mitral regurgi-
D) Hydralazine. tation is not likely to be hemodynamically signi cant. “D” is
E) ARBs. incorrect because with a right ventricular in arct, you would
expect to see a poorly unctioning right ventricle. “E” is incor-
Answer 2.8.5 The correct answer is “B.” Beta-blockers, espe- rect because a Chiari network is normal vestigial variant in the
cially metoprolol succinate, are use ul as initial therapy in right atrium and would not cause RVH.
HFpEF. Beta-blockers (1) slow down the heart to permit lon-
ger LV lling duration during diastole and (2) help to relax Question 2.9.2 Cor pulmonale (not right ventricular ailure)
the myocardium to promote a less restrictive lling pattern. I may result rom all o these disease processes EXCEPT?
a patient ails beta-blockers, try a CCB (e.g., verapamil, diltia- A) Sickle cell anemia.
zem). Unlike systolic dys unction, the treatments o diastolic B) Le ventricular ailure.
dys unction are not well established, and there is no convinc- C) PE.
ing evidence that beta-blockers or ACE inhibitors reduce D) Chronic obstructive lung disease.
mortality. E) Interstitial lung disease.
CHAPTER 2 • CAr Dio l o Gy 65

Answer 2.9.2 The correct answer is “B.” Cor pulmonale is the Objectives: Did you learn to . . .
term used or right heart ailure caused by diseases primarily • D agn se c pu m na e?
a ecting the lungs and pulmonary vasculature. T e chronic pres- • Desc be causes c pu m na e?
sure overload o the right ventricle as it ejects in to the high resis- • T eat a pat ent w th c pu m na e?
tance pulmonary vasculature results initially in RVH with normal
RV systolic unction but over time, the RV contractility declines
leading to RV dilation and right-sided heart ailure with associ- CASE 2.10
ated signi cant tricuspid regurgitation and right atrial dilation.
A 65-year-old male presents to your clinic or a complete his-
Question 2.9.3 A possible nding on the ECG o this patient tory and physical examination. You notice that his abdomi-
would include: nal examination reveals a pulsatile mass, which you sus-
A) P-mitrale (an “m” shaped, notched P wave in lead II). pect may represent an aortic aneurysm (now we are tired o
B) P-pulmonale (an enlarged, peaked, P wave in lead II). writing heart ailure questions). T is nding is con rmed
C) Absent P waves. by ultrasound. T e radiologist reports that the patient has a
D) Inverted P waves. 3.5-cm abdominal aortic aneurysm without evidence o leak
or thrombus ormation.
Answer 2.9.3 The correct answer is “B.” Patients with cor pul-
monale o en have an enlarged and peaked P wave in lead II Question 2.10.1 The best advice to this patient is:
ref ecting right atrial enlargement. “P-mitrale” is ound in le A) Have the aortic aneurysm xed now while he is still
atrial enlargement. healthy.
Question 2.9.4 Besides stopping smoking, the best treat B) Have a ollow-up ultrasound every 3 months.
ment o this patient’s cor pulmonale and pulmonary hyper C) Have a stent placed to prevent urther aortic dilatation.
tension (PHTN) is: D) Have an angiogram in the next several days to rule out vas-
A) Continuous prostacyclin in usion. cular disease below the aorta ( emoral arteries, iliac arteries,
B) Continuous, low f ow oxygen. etc.).
C) CCBs. E) Have a repeat ultrasound at 1 year.
D) Nitroglycerin.
E) Antibiotics to reduce pulmonary inf ammation secondary Answer 2.10.1 The correct answer is “E.” Patients with an
to in ection. abdominal aortic aneurysm less than 4 cm in diameter should
have an ultrasound yearly to check progression. T ose with an
Answer 2.9.4 The correct answer is “B.” In this patient who is a aneurysm 4 to 5 cm in diameter should have an ultrasound
smoker with cor pulmonale, the best drug is continuous, low-f ow every 6 months. An ultrasound on an every 3 to 6 months basis
oxygen. T is will help to reverse the pulmonary vasoconstriction is also indicated or aneurysms that are growing >0.5 cm per
caused by chronic hypoxia. It should go without saying that you year. Bottom line: the larger the aneurysm, the more requently
must do everything you can to get him to stop smoking. His dis- should do an ultrasound. “A” is incorrect (see next question or
ease process will progress much aster i he continues to smoke. an explanation). “C” is incorrect since a stent is not indicated at
“A” is incorrect because prostacyclin in usion is use ul in primary this point. “D” is incorrect. T e only reason to do an angiogram
pulmonary hypertension (PH N), not this type o cor pulmonale. at this point is i the patient is symptomatic or i you are plan-
“C” is incorrect. In some cases o primary PH N, CCBs, PDE5 ning surgical intervention.
inhibitors (e.g., sildena l), and several other medications, which
serve as direct vasodilators to dilate the pulmonary vascular bed, Question 2.10.2 The patient is really worried that this aneu
can be use ul. However, this is not the best choice or this patient rysm will rupture and kill him. You educate him that the
with COPD. “D” is incorrect because patients with cor pulmonale bene t o having the aneurysm repaired is greater than the
are dependent on high right heart lling pressures to get blood risk o the surgery when the aneurysm reaches:
through the pulmonary vasculature. Nitroglycerin will reduce pre- A) ≥4.5 cm.
load, thereby lowering right ventricular pressure and resulting in B) 5.0 to 5.5 cm.
worsening o his symptoms. “E” is also incorrect. Antibiotics might C) 5.5 to 6.0 cm.
be needed in this patient or pneumonia, bronchiectasis, etc., but D) >6.0 cm.
they are not going to help with the treatment o cor pulmonale. E) No repair is indicated until the patient becomes symptom-
r emembe s eep apnea as a cause c pu m na e. N c- Answer 2.10.2 The correct answer is “B.” T e risk o the sur-
tu na x gen desatu at n causes nc eased pu m na gery outweighs the bene ts until the aneurysm reaches some-
vascu a es stance caus ng e evated ght vent cu a where between 5.0 and 5.5 cm. T e rest are incorrect. It would
p essu e and p ss b ght-s ded a u e seve e and be an especially bad idea to wait until an aneurysm is symptom-
unt eated. atic, as a ruptured aortic aneurysm can be lethal in a matter o
66 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW

Esmolol is pre erred because o the short hal -li e; you easily can
turn it o i there is hypotension. Nitroprusside (or our avor-
Pe cutane us end vascu a stent g a t epa s bec m-
ite, IV nitroglycerin) can be added i the blood pressure control
ng the p cedu e ch ce as c mpa ed t pen epa .
remains suboptimal even a er beta-blockade. In this scenario,
But the e a e t ade s: 30 da m ta t m an end -
nitroprusside should never be given without beta-blockade, as
vascu a g a t s 1.6% ve sus 3.2% pen epa , but at
it may cause ref ex tachycardia induced by vasodilation and
8 ea s uptu e ate was 5.4% ve sus 1.4%. o ve a 8- ea
thus urther aortic shear stress. T e same rationale is true or
m ta t s the same (N Eng J Med. 2015;373:328).
not using intravenous hydralazine without beta-blockers in
this scenario. “A” is incorrect or two very good reasons. First,
ni edipine should never be used sublingually. Syncope, heart
T e patient goes to exas (or Arizona or Florida—somewhere block, MI, stroke, and other serious adverse consequences have
warmer than Iowa) or the winter as part o the re-establish- been reported. Second, ni edipine increases heart rate causing
ment o human annual migration. When he returns, he calls an increase in shear orces on the aorta. “B” is incorrect since
you complaining o back pain that is somewhat sharp and amlodipine does nothing to reduce heart rate, is not titratable to
radiating into his legs. You meet him in the ED and suspect any use ul degree, and the onset o action is too slow to be used
that he is having a dissection o his aneurysm. when prompt blood pressure lowering is desired. “E” is incor-
rect because nitroglycerin alone causes ref ex tachycardia.
Question 2.10.3 All o the ollowing are true regarding aor
tic dissection EXCEPT:
A) A substantial number o patients will have palpable pulses
Sc een an a t c aneu sm once n men age 65 t
below the level o the dissection.
75 wh have eve sm ked (pe USPSTF and ACC/AHA
B) Patients may have an elevated LDH and microangiopathic
gu de nes).
ndings on RBC examination.
C) Blood pressure should be kept on the high side to ensure
per usion below the area o the aneurysm.
D) T e pain may migrate down rom the chest to the lower Objectives: Did you learn to . . .
abdominal area over time. • ident the t eatment pt ns and t m ng t eatment an
E) T e pain may be episodic. abd m na a t c aneu sm?
• Manage a pat ent w th a d ssect ng aneu sm?
Answer 2.10.3 The correct answer is “C.” One does not want
to keep the blood pressure on the high side. In act, reducing
the blood pressure is the initial treatment o choice or a dissect-
CASE 2.11
ing aneurysm. “A,” “B,” “D,” and “E” are all correct statements. A 60-year-old male presents with dizziness and palpitations.
Patients may have an elevated LDH and microangiopathic nd- T e patient has a blood pressure o 100/60 mm Hg and a
ings on RBC smear as a result o trauma and cell lysis. “D” is a pulse o 160. His ECG is shown in Figure 2-3.
correct statement, but patients o en do not have this “classic”
migrating pattern o pain. “E” is o en true o pain in aortic dis- Question 2.11.1 Which o the ollowing interventions are
section—it may be episodic. appropriate options in the treatment o this patient?
A) Amiodarone, lidocaine, de brillation, metoprolol.
T e patient has a blood pressure o 160/105 mm Hg. Clearly, B) Amiodarone, lidocaine, de brillation, diltiazem.
this is too high in a patient who has an ongoing dissection. C) Amiodarone, lidocaine, cardioversion, diltiazem.
You decide to treat this patient be ore trans erring him to a D) Procainamide, lidocaine, adenosine, de brillation.
tertiary care center where he can be surgically managed. E) Amiodarone, procainamide, lidocaine, cardioversion.

Question 2.10.4 The best medication(s) to use in this Answer 2.11.1 The correct answer is “E.” T e rhythm is stable
patient to control his blood pressure is/are: ventricular tachycardia. Procainamide, lidocaine, amiodarone,
A) Sublingual ni edipine plus metoprolol. and synchronized cardioversion can all be used or ventricular
B) Amlodipine. tachycardia. “A” is incorrect or two reasons. T e rhythm is ven-
C) Intravenous hydralazine. tricular tachycardia and is stable, and neither metoprolol nor
D) Intravenous esmolol plus nitroprusside. de brillation is appropriate. De brillation could be appropriate
E) Intravenous nitroglycerin. i the patient was unstable, pulseless (including pulseless ven-
tricular tachycardia) or had ventricular brillation. “B” is incor-
Answer 2.10.4 The correct answer is “D.” T e goal o ther- rect because o the inclusion o diltiazem and de brillation. “C”
apy here is not only blood pressure reduction but also control is incorrect because o the inclusion o diltiazem. “D” is incor-
o shear orces on the aorta, which requires the prevention rect because adenosine, which is used or atrial arrhythmias, is
o tachycardia. Intravenous beta-blockers such as labetalol, useless in ventricular arrhythmias and because, again, de bril-
propranolol, metoprolol, or esmolol are the rst-line agents. lation is inappropriate.
CHAPTER 2 • CAr Dio l o Gy 67

FIGURE 2-3. ECG pat ent n quest n 2.11.1.


P ca nam de s n nge n the ACl S p t c s. it s F defibrillation, esca at ng d ses e ect c t a e
st a ea g d d ug u have the t me t ad t. ut the new p t c s. Sta t w th a s ng e sh ck at
360 j u es w th a m n phas c de b at 150 t 200
Question 2.11.2 The patient does not respond to IV amio j u es us ng a b phas c de b at .
darone and you choose to cardiovert him. Which o the ol
lowing is the recommended energy (in joules) or an initial
attempt at synchronized cardioversion?
A) 200 joules, monophasic. You cardiovert the patient, and the rhythm in Figure 2-4 is on
B) 360 joules, monophasic. the monitor. Is it getting hot here, or is it just you?
C) 200 joules, biphasic.
D) 360 joules, biphasic. Question 2.11.3 O the ollowing, what is the rst step you
E) None o the above. will take (while maintaining good compressions and venti
lations, o course)?
Answer 2.11.2 The correct answer is “A.” For cardioversion o A) Reshock the patient at the same energy level.
stable ventricular tachycardia, start with 100 to 200 joules or B) Check another lead to assure the readout is accurate.
monophasic wave orms and 100 joules or biphasic wave orms. C) Give epinephrine, 1 mg IV.
T e rest are incorrect. D) Give atropine, 1 mg.

FIGURE 2-4. ECG pat ent n quest n 2.11.3.

68 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW

Answer 2.11.3 The correct answer is “B.” T is rhythm is asys- Question 2.11.4 The new lead placement continues to show
tole. It is important to quickly check another lead and make asystole. Which o the ollowing drugs and doses are con
sure that all o the leads are connected properly. “A” is incorrect sidered appropriate in asystole?
because cardioversion/de brillation is not routinely indicated A) Epinephrine 1 mg.
in the treatment o asystole. “C” and “D” are incorrect because B) Atropine 0.5 mg.
it is important to ensure that the patient actually is in asystole. C) Atropine 1 mg.
D) Epinephrine 10 mg.
W th ega d t ACl S, d ng c mp ess ns and vent a-
t ns a e pa t cu a mp tant. The e s n need t n- Answer 2.11.4 The correct answer is “A.” Atropine is no
tubate the pat ent he/she can be eas bagged. The longer in the ACLS guidelines or asystole. Older ACLS rec-
c ect numbe vent at ns (10–12/m n) and c m- ommendations or asystole included both epinephrine and
p ess ns (100 bpm w th 2 n depth) n a at 15 atropine.
c mp ess ns: 2 b eaths tw p v de CPr 30:1 Objectives: Did you learn to . . .
s ng e p v de s mp tant. The Bee-Gees “Sta - • r ec gn ze and manage vent cu a tach ca d a and as st e?
ng A ve” has the c ect ate c mp ess ns. Queen
• App the cu ent Ame can Hea t Ass c at ns ACl S gu de-
“An the o ne B tes the Dust” a s has the c ect ate nes t a pat ent n as st e?
but s c ns de ed ess dec us n the c de s tuat n (
c u se, u d n’t have t s ng t ut ud!). i u kn w
ne the th se s ngs, u a e n t qu te as d as we a e. CASE 2.12
A 75-year-old emale presents to your o ce complaining o
HELPFUL (AND VERY IMPORTANT) TIP: episodic palpitations with episodes o lightheadedness that
The 2010 and 2015 AHA gu de nes ACl S emphas ze the are not concurrent with the palpitations. You per orm an
mp tance sta t ng w th chest c mp ess ns (C–A–B) and electrocardiogram in your o ce, and the rhythm is shown
NEVEr nte upt ng chest c mp ess ns du ng esusc tat n in Figure 2-5.
( ea that means m n m z ng nte upt ns—the ee that
t ten chest c mp ess ns a e ha ted ess mp tant Question 2.12.1 What rhythm does this represent?
nte vent ns such as ntubat n, ven us access, etc.). A) First-degree heart block.
B) Second-degree heart block type I (Wenckebach).

FIGURE 2-5. ECG pat ent n quest n 2.12.1.

CHAPTER 2 • CAr Dio l o Gy 69

C) Second-degree heart block type II. bradycardia episodes. T us, pacing is necessary. (Note: A pace-
D) T ird-degree heart block. maker would also be indicated in patients with Mobitz type II
E) Atrial f utter with variable block. second-degree heart block without tachy-brady syndrome).
“A” and “C” are incorrect because these two drugs are aimed
Answer 2.12.1 The correct answer is “C.” Your patient’s ECG primarily at ventricular arrhythmias; sick sinus syndrome is a
shows a second-degree heart block, type II (Mobitz II). T is is problem with the SA node. “B” is incorrect because hydralazine
characterized by a xed PR interval with an intermittently non- is an a erload reducer with no direct e ect on cardiac rhythm.
conducting P wave and resultant dropped beats. “A” is incor- “E” is incorrect because patients with sick sinus syndrome do
rect. First-degree heart block is characterized by a prolonged not have ventricular brillation or ventricular tachycardia, and
PR interval without any blocked beats (meaning every QRS is thus there is no need or a de brillator.
preceded by a P wave conducted with a long PR interval). T e
upper limit o normal o the PR interval is 0.2 seconds (and we
admit that this one is darn close, but Mobitz II is the issue here). HELPFUL TIP:
A second-degree heart block, Mobitz type I (Wenckebach), is in s ck s nus s nd me, n add t n t the pacemake , t
de ned by a progressively prolonged PR interval ending with a s ten necessa t add a beta-b cke , d g x n, a
nonconducted P wave and a dropped beat. A third-degree heart CCB (d t azem ve apam ) t add ess the tach ca d a
block is characterized by no consistent pattern between the P (e.g., PSVT at a b at n).
waves and the QRS complex. “E” is incorrect because, by de -
nition, atrial f utter is represented by a rapid atrial rate. In this
patient, the rate is slow. Objectives: Did you learn to . . .
• ident and d f e ent ate sec nd-deg ee hea t b cks?
By the time the patient arrives at the hospital, she is having a • D agn se and t eat s ck s nus s nd me?
rapid, chaotic rhythm, which appears to be atrial brillation
on the monitor. It seems as though there are also episodes o CASE 2.13
atrial utter with 2:1 block.
A 58-year-old male smoker with a history o type 2 diabetes
Question 2.12.2 The most likely diagnosis in this patient mellitus presents with complaints o easy atigability and
with varying rate is: pain in his thighs when exerting himsel . T e le leg is worse
A) Sick sinus syndrome (bradycardia–tachycardia syndrome). than the right. T e pain resolves a er resting and is no worse
B) Hypothyroidism. going downhill than uphill. He works as a carpenter, and the
C) Hyperthyroidism. leg pain is now limiting his ability to work. He will not quit
D) Hyperkalemia. smoking (“It’s the only thing I truly love, Doc”). T e patient
states that his symptoms are better when he hangs his leg over
Answer 2.12.2 The correct answer is “A.”T e most likely diagno- the side o the bed at night.
sis in this patient is “sick sinus syndrome,” also known as “tachy–
brady” syndrome and “bradycardia–tachycardia” syndrome. T is Question 2.13.1 The etiology o this patient’s leg pain is
syndrome is most common in elderly individuals and ref ects the most likely:
replacement o the SA node with brous tissue. “B” is incorrect A) Peripheral venous disease (e.g., venous insu ciency, vari-
because hypothyroidism should cause bradycardia without inter- cose veins).
mittent tachycardia. “C” is incorrect because hyperthyroidism B) Spinal stenosis.
should cause tachycardia without bradycardia. “D” is incorrect C) Diabetic neuropathy.
because hyperkalemia generally causes a widened QRS complex D) Peripheral arterial disease (e.g., arterial stenosis).
on ECG and eventually ventricular tachycardia. Note: With Mob- E) None o the above.
itz type II second degree heart block, the problem is in ra-nodal,
below the AV node and can result in complete heart block. Sick Answer 2.13.1 The correct answer is “D.” Intermittent claudi-
sinus syndrome is due to disease o the SA node. cation is the classic presenting symptom o peripheral arterial
disease. When rest pain is present, relie o symptoms occurs by
Question 2.12.3 De nitive treatment o this syndrome making the a ected area dependent (e.g., hanging the legs over the
generally includes which o the ollowing? side o the bed), letting gravity help increase blood f ow. T e pain
A) Mexiletine. associated with diabetic neuropathy begins distally, has a burning
B) Hydralazine. quality, and is not typically relieved with rest. In act, patients o en
C) Quinidine. notice it more at rest (e.g., during the night). Patients with periph-
D) Pacemaker. eral venous disease will o en have worsening o their symptoms
E) Implantable de brillator. when their legs in a dependent position. Spinal stenosis is o en
made worse by walking downhill and better when walking uphill
Answer 2.12.3 The correct answer is “D.” In general, patients or leaning orward (a kyphotic/ orward f exed position opens up
with sick sinus syndrome become symptomatic because o the the oramen thereby decreasing nerve root compression).
70 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW

0.94 represents mild arterial disease that may or may not be

His examination shows decreased pulses in the lower extrem- associated with claudication. An ABI o 0.41 to 0.80 is classi-
ities bilaterally. You would like to con rm your suspicion ed as moderate arterial disease and is usually associated with
that this patient has peripheral vascular disease. some degree o claudication. An ABI o ≤0.4 represents severe
disease and may be associated with rest pain. Paradoxically, an
Question 2.13.2 What is the rst study you would order in ABI > 1.30 represents noncompressible arteries and may be a
this patient? marker or arterial calci cation. In these cases, a toe-brachial
A) Spiral C to con rm vascular calci cation. index should be measured (really). (Don’t ask us . . . we don’t
B) Ankle-brachial index (ABI). know where to nd a toe BP cu either. Maybe you can use a
C) Color Doppler to assess f ow. ull-sized gnome or pixie cu . We’d love to sell you one).
D) Catheter based arteriography.
E) None o the above is the recommended rst test. You decide to start the patient on a medication to help control
his claudication.
Answer 2.13.2 The correct answer is “B.” T e ABI is sensitive and
speci c or peripheral arterial disease in the lower extremity. T e Question 2.13.5 Which o the ollowing statements is
pressure in the ankle should be higher than that in the brachial correct?
artery in a normal person. T e highest sensitivity is achieved by A) Pentoxi ylline is relatively contraindicated in heart ailure.
measuring pressures in both brachial arteries, both dorsalis pedis, B) Cilostazol is the best choice or claudication in patients with
and both posterior tibial arteries. Neither spiral C or color Dop- heart ailure.
pler are recommended as the initial screening test or the presence C) Beta-blockers are good arterial dilators and are thus use ul
o peripheral vascular disease (although C angiogram may be in claudication.
use ul in the uture to de ne the degree and location o narrowing). D) T e main mechanism o action o pentoxi ylline and cilo-
Catheter based arteriography is an option but should be reserved stazol is selective vasodilation.
or patients with known peripheral artery disease in whom inter- E) obacco smoking paradoxically alleviates claudication.
vention (percutaneous or surgical) is being considered.
Answer 2.13.5 The correct answer is “A.” Cilostazol (Pletal)
T e ABI results are normal. However, you strongly suspect and pentoxi ylline ( rental) are phosphodiesterase inhibitors.
claudication. T eir mechanism o action in improving walking distance is
poorly understood. Other phosphodiesterase inhibitors (such
Question 2.13.3 The next step should be: as milrinone) increase mortality in patients with heart ailure.
A) Catheter based arteriography. T us, pentoxi ylline and cilostazol should be used with extreme
B) Repeat ABI a er an exercise stress test. caution, i at all, in patients with heart ailure. Selective beta-
C) Magnetic resonance arteriography. blockers actually cause peripheral arterial constriction, not
D) C arteriography. arterial dilation. “C” is also incorrect. T e purported bene t o
E) None o the above. pentoxi ylline is to increase RBC malleability and thus reduce
the viscosity o blood in the microcirculation. It has no vasodi-
Answer 2.13.3 The correct answer is “B.” In patients in whom lative e ects. However, cilostazol does have some vasodilative
you strongly suspect peripheral vascular disease, ankle-brachial e ects. T erapeutic bene t with these drugs may take several
indices a er exercise can be positive when a resting test is nega- weeks. A dedicated and supervised walking program is o para-
tive. T is would be the least invasive and most cost-e ective test mount importance and underutilized. Given the strong associa-
o the options given. tion between smoking and peripheral artery disease, smokers
should be encouraged to quit, so “E” is incorrect. Pharmaco-
T e postexercise ankle-brachial indices are as ollows: 0.9 in logic therapy o PAD should include antiplatelet therapy and
the right leg, 0.4 in the le leg. cardiovascular risk actor modi cation.

Question 2.13.4 The proper interpretation o this in orma HELPFUL TIP:

tion is: r emembe that pe phe a a te d sease s c ns de ed
A) 95% probability o some degree o occlusive disease in the a CAD equ va ent.
right leg, severe occlusive disease in the le .
B) No occlusive disease in the right leg, mild disease in the le .
C) Moderate occlusive disease on both sides. Question 2.13.6 In and o themselves, indications or ur
D) No occlusive disease in either leg. ther intervention or peripheral artery disease (e.g., bypass,
stenting) include all o the ollowing EXCEPT:
Answer 2.13.4 The correct answer is “A.” A normal ABI A) Rest pain.
should be 0.95 to 1.29. An ABI o 0.9 is 95% sensitive or nding B) Persistent pain that inter eres with day-to-day unctioning.
some degree o occlusive disease on arteriography (although it C) issue loss.
may not be hemodynamically signi cant). An ABI o 0.81 to D) 80% occlusion o the emoral artery.
CHAPTER 2 • CAr Dio l o Gy 71

Answer 2.13.6 The correct answer is “D.” Classic indications Answer 2.14.1 The correct answer is “D.” As a general rule, aor-
or invasive treatment o lower extremity PAD are (1) salvage tic stenosis is repaired when it becomes symptomatic. Repair o
o a threatened limb (rest pain, nonhealing ulceration, or gan- asymptomatic severe aortic stenosis is indicated in the ollowing
grene) and (2) improvement in unctional capacity. An 80% scenarios: undergoing CABG or other valve or aorta surgery, LVEF
occlusion o the emoral artery, in and o itsel , is not an indica- < 50%, hypotension in response to exercise, or high likelihood o
tion or percutaneous or surgical revascularization in a patient rapid progression. “A” is incorrect because the loudness o the
who is asymptomatic. murmur does not always correlate with its unctional signi cance.
“B” is incorrect as well. As long as the lesion is not hemodynami-
T e patient sees the light, but does not go into it, and quits cally signi cant, the patient should tolerate prostate surgery. “C” is
smoking. T e case ends happily . . . incorrect because surgery is not usually necessary even in severe
valvular disease without symptoms as long as the le ventricular
HELPFUL TIP: unction is normal. (Note: it is not uncommon that patients with
N ant c agu at n eg men seems t p event e cc u- severe aortic stenosis report that they are asymptomatic, but they
s n we ext em t a te es a te stent ng. Pat ents have modi ed their activity to avoid symptoms which may have
sh u d, h weve , c nt nue n the cu ent ant th m- occurred gradually so that they don’t recognize the decline.)
b t c eg men as nd cated ca d vascu a d sease
(ASA, wa a n, etc.). Question 2.14.2 The patient would like to know how o ten
he should have a repeat echocardiogram given that he has
Objectives: Did you learn to . . . mild disease. Your answer is:
• r ec gn ze s mpt ms and s gns pe phe a vascu a d sease?
A) Every 3 to 5 years.
B) Every year.
• o de app p ate d agn st c tests a pat ent suspected
hav ng pe phe a vascu a d sease?
C) Every 6 months.
D) When he develops symptoms.
• Deve p an unde stand ng the agents used t t eat pe-
phe a vascu a d sease?
E) None o the above.

Answer 2.14.2 The correct answer is “A.” Patients with mild

CASE 2.14 aortic stenosis who are asymptomatic can be ollowed by echo-
cardiogram every 3 to 5 years. Patients with severe disease
A 75-year-old male presents to your o ce or a complete should have yearly echocardiography to evaluate or le ven-
physical examination be ore prostate surgery. On examina- tricular dys unction. See able 2-7.
tion, you notice a 3/6 harsh, mid-systolic ejection murmur
hard best at the upper right sternal border and radiating to wo years later, the patient returns or a checkup and states
the neck. S1 and S2 are normal. An echocardiogram notes that he believes he has been having symptoms rom his aortic
mild aortic stenosis. Currently he is asymptomatic. stenosis.

Question 2.14.1 The indications or valve replacement Question 2.14.3 All o the ollowing can occur with symp
surgery include: tomatic aortic stenosis EXCEPT:
A) Grade 4/6 murmur. A) Le -to-right intracardiac shunt.
B) Requirement or major, semi-elective surgery such as pros- B) Exertional dyspnea.
tatectomy. C) Syncope.
C) Severe aortic stenosis without symptoms and normal LV D) Angina.
unction. E) Lightheadedness.
D) Severe aortic stenosis in a patient undergoing coronary
bypass gra ing. Answer 2.14.3 The correct answer is “A.” Intracardiac shunts
E) All o the above. don’t occur with aortic stenosis. I you got this one wrong, back


Lesion Mild Disease Moderate Disease Severe Disease
A t c sten s s Eve 3–5 ea s Eve 2 ea s Eve 6–12 m nths

M t a sten s s Eve 3–5 ea s Eve 1–2 ea s Eve 1–2 ea s

A t c egu g tat n Eve 3–5 ea s Eve 1–2 ea s Eve 6–12 m nths

M t a egu g tat n Eve 3–5 ea s Eve 1–2 ea s Eve 6–12 m nths

r ec mmendat ns va .
72 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW

to anatomy or you! An isolated, xed valvular lesion as an adult Question 2.15.1 What is your initial approach to this
cannot cause intracardiac shunting. Exertional dyspnea, light- patient?
headedness (presyncope), syncope, and chest pain are common A) Start a chronic antihypertensive since he is at risk or a stroke
symptoms in severe aortic stenosis. within the next couple o days with a blood pressure at this
Question 2.14.4 Which o the ollowing statements about B) Administer clonidine in the o ce to reduce the blood pres-
aortic valve disease is INCORRECT? sure to a sa e level o about o 150/100 mm Hg.
A) Aortic stenosis can be treated quite e ectively with valvu- C) Watch the patient over the next 2 weeks and get additional
lotomy (balloon aortic valvuloplasty). blood pressure readings be ore deciding what to do and
B) T ere are no known medical treatments that reduce the instruct him to discontinue pseudoephedrine.
need or aortic valve replacement. D) Schedule the patient or outpatient labs and electrocardio-
C) Risk actors or the development o aortic stenosis are simi- gram.
lar to CAD. E) Fire the patient rom your practice. He’s messing up your
D) Valve replacement surgery is the pre erred treatment o quality measures.
symptomatic aortic stenosis.
Answer 2.15.1 The correct answer is “C.” T e diagnosis o
Answer 2.14.4 The correct answer (and what doesn’t work) hypertension requires two elevated blood pressures on two di -
is “A.” Valvulotomy (balloon aortic valvuloplasty) is not a long- erent occasions. T is patient’s elevated blood pressure could be
term solution or the management o severe symptomatic aortic situational, related to decongestants and current illness. Neither
stenosis. While it may be indicated as a “bridge” to de nitive “A” nor “B” is correct because a blood pressure o 175/103 mm
treatment (surgery or transcatheter aortic valve replacement Hg does not pose a risk o acute stroke, and the pressure need
[ AVR]), durability o the valvulotomy results are poor, only not be lowered acutely unless there is evidence o end-organ
lasting 3 to 6 months. T e procedure carries the attendant risk injury (e.g., angina, heart ailure, hypertensive encephalopathy).
o cerebral embolism causing stroke, aortic rupture, or acute “D” is incorrect because you cannot de nitively establish that
severe aortic insu ciency. Valve replacement surgery is pre- this patient has hypertension based on only one in o ce blood
erred although AVR (see below) can be considered in the pressure measurement. As or “E” . . . really? Is this why we went
nonsurgical candidate. T e epidemiological risk actors or aor- into medicine?
tic stenosis and CAD are similar (as is the pathophysiology).
Un ortunately, there are no drugs that are e ective at reducing
T e patient returns to your o ce with blood pressures mea-
the need or valve replacement. You can provide symptomatic
sured six times over a period o 2 weeks at a local pharmacy.
relie but that is all.
Only three o the six readings suggest that the patient is
hypertensive. T e patient states that the elevated blood pres-
HELPFUL TIP: sures were while he was under stress at work.
in pat ents wh a e n t cand dates pen su g ca
a t c va ve ep acement, a cathete -based app ach Question 2.15.2 Your best response at this point is to:
ep acement the a t c va ve (t anscathete a t c A) Start an antihypertensive.
va ve ep acement “TAVr ”) s ava ab e. TAVr appea s B) Send the patient or a 24-hour ambulatory blood pressure
t educe ve a m ta t c mpa ed w th standa d measurement.
n nsu g ca ca e but nc eases the sk st ke. C) Don’t worry about the blood pressure since the majority o
the readings were within a normal range.
D) Get a nephrology consult to help in decision making.
E) Make another o ce visit so you can buy that Porsche.
Objectives: Did you learn to . . .
• r ec gn ze s mpt ms a t c sten s s?
• Manage a pat ent w th a t c sten s s? Answer 2.15.2 The correct answer is “B.” One way to deter-
• Eva uate a t c va ve d sease and dete m ne ng-te m
mine i a patient with contradictory readings is hypertensive
w-up v s-à-v s pe d c ech ca d g ams? is to per orm 24-hour ambulatory blood pressure monitoring.
T is can be use ul in patients who have elevated blood pres-
sures in the o ce but not at home or vice versa. It can also be
used i you do not trust the blood pressure readings taken out-
CASE 2.15 side o your o ce. “A” is incorrect since we have not yet estab-
A 35-year-old male presents to the o ce with upper respi- lished that this patient is hypertensive. “C” is incorrect since we
ratory symptoms. He is taking no medications except or a have not yet established that this patient is not hypertensive.
bit o pseudoephedrine or his cold. You notice when look- “D” is incorrect because you are smarter than that and should
ing at his vital signs that his blood pressure is 180/106 mm be able to work through this kind o case yoursel ! As to “E,”
Hg. Repeat measurement con rms that the blood pressure is whoops, we orgot. We’re amily physicians, not radiologists.
elevated at 175/103 mm Hg. No Porsche or us!
CHAPTER 2 • CAr Dio l o Gy 73

Question 2.15.3 The ollowing are all well accepted indica Question 2.15.6 The initial evaluation o the hypertension
tions or 24 hour ambulatory blood pressure monitoring includes the ollowing:
EXCEPT: A) History, physical, CBC, urinalysis, glucose, BUN, creatinine,
A) Suspected white coat hypertension. electrolytes, ECG, and lipids.
B) Patients with di cult-to-control hypertension. B) History, physical, CBC, uric acid, glucose, BUN, creatinine,
C) Patients having hypotensive symptoms on their antihyper- electrolytes, and lipids.
tensive treatment. C) History, physical, CBC, urinalysis, glucose, BUN, creatinine,
D) Follow-up a er initiating antihypertensive treatment. electrolytes, ECG, lipids, and echocardiography.
E) Evaluation o patient or autonomic dys unction. D) History, physical, and labs only as indicated by history and
Answer 2.15.3 The correct answer is “D.” One need not do
24-hour ambulatory blood pressure monitoring to document Answer 2.15.6 The correct answer is “A.” History, physical,
response to antihypertensive therapy in patients in whom CBC, urinalysis, glucose, BUN, creatinine, electrolytes, ECG,
most or all measurements posttreatment are normal. All o the and lipids are the generally agreed-upon initial work-up o the
other answer choices are considered reasonable indications or hypertensive patient. Do we really need all o these? T at is
24-hour ambulatory blood pressure monitoring. an interesting question, but we’re just stating what is recom-
mended by the experts. “C” includes echocardiography, which
Elevated blood pressure in response to stress (especially in is not recommended as part o the routine evaluation but may
the doctor’s o ce) is called “white coat hypertension.” be indicated i signs o cardiac disease are present.

Question 2.15.4 Which o the ollowing statements is true T e patient’s ECG comes back showing evidence o LVH.
about white coat hypertension?
A) As long as the majority o blood pressure readings are nor- Question 2.15.7 This nding suggests that:
mal, the patient does not require treatment because there is A) You should initiate this patient’s therapy with an ACE inhib-
no increased risk o adverse cardiac outcomes. itor since ACE inhibitors prevent disadvantageous cardiac
B) Patients with white coat hypertension have an intermedi- remodeling.
ate risk or adverse outcomes when compared with patients B) T e patient has heart ailure.
with normal blood pressure and those with chronically ele- C) You should recommend an echocardiogram or this patient.
vated blood pressure. D) You should order a BNP level to screen or LVH and early
C) White coat hypertension is more common in young patients. heart ailure.
D) Patients with white coat hypertension have an elevated le
ventricular mass when compared to patients with normal
blood pressures. Answer 2.15.7 The correct answer is “C.” T e sensitivity o
E) B and D. ECG or LVH is only in the 30% to 60% range with a speci city
o 80%. T us, a “positive” ECG is not a strong enough indication
Answer 2.15.4 The correct answer is “E.” Patients with white to initiate therapy or LVH. For this reason, an echocardiogram
coat hypertension have outcomes that are intermediate between should be done to con rm the diagnosis o LVH. “A” is incor-
normotensive and hypertensive patients. In addition, they have rect since an ACE inhibitor is not necessarily the rst drug one
an elevated le ventricular mass. Surprisingly, white coat hyper- would start. In addition, we really don’t know i this patient has
tension is more common in the elderly. LVH yet, though ACE inhibitors do prevent harm ul cardiac
remodeling. “B” is incorrect. Certainly, long-standing hyperten-
Question 2.15.5 Hypertension is de ned as an ambulatory sion and signi cant LVH can cause heart ailure. However, we
24 hour monitor average blood pressure o : cannot conclude that this patient has heart ailure on the basis
A) 135/85 mm Hg during the day and 125/75 mm Hg at night. o an ECG, especially in the absence o symptoms. “D” is incor-
B) 140/90 mm Hg during the day and 130/85 mm Hg at night. rect since the sensitivity o the BNP as a screening tool in an
C) 130/85 mm Hg over 24 hours. asymptomatic population is poor.
D) 140/90 mm Hg over 24 hours.
T e echocardiogram is normal. You have decided to start this
Answer 2.15.5 The correct answer is “A.” Patients with an patient on treatment or his hypertension.
average blood pressure o >135/85 mm Hg during the day and
>125/75 mm Hg at night are de ned by JNC 7 as being hyperten- Question 2.15.8 Based on outcome data, the LEAST ef ec
sive; JNC 8 has not changed this. Another published criterion is tive drug to start on this patient?
a blood pressure o >140/90 mm Hg more than 40% o the time. A) An ACE inhibitor, such as lisinopril.
B) An ARB, such as losartan.
T e ambulatory blood pressure monitor reveals that the C) An alpha-blocker, such as doxazosin.
patient’s blood pressure is >140/90 mm Hg more than 40%o D) A thiazide diuretic, such as chlorthalidone.
the time, indicating that he is indeed hypertensive. E) A CCB, such as amlodipine
74 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW

Answer 2.15.8 The correct answer is “C.” Alpha-blockers have Answer 2.15.10 The correct answer is “B.” Doxazosin is an
worse outcomes in hypertension when compared to other anti- alpha-blocker that is use ul in the treatment o symptomatic
hypertensives. T e JNC 8 recommendations suggest that the BPH. None o the other choices can be used or this indication.
rst line agent, in the general nonblack population, including O course, alpha-blockers are also antihypertensives, and thus
those with diabetes, could appropriately be a thiazide-type serve a use ul purpose by killing two birds with one stone (Why
diuretic, CCB, ACEI or ARB. Notice that beta-blockers do not would you want to kill two birds? And why with stones? Isn’t
make the list o rst-line antihypertensives either. For the gen- there a better way?). Note: T ere is some evidence that alpha-
eral black population, including those with diabetes, the ini- blockers do not con er as much bene t or the hypertensive
tial antihypertensive treatment should include a thiazide-type patient as other classes o drugs. T us, alpha-blockers are not
diuretic or a CCB. the best choice in general but could be used as the initial agent
i you have a compelling reason.
Question 2.15.9 Time to digress a bit. Which o the ollow T e point o these digressions is that you should look at the
ing drugs is the best choice as your initial agent or the patient’s other underlying illnesses when deciding what to rec-
treatment o hypertension in a patient with diabetes and ommend at initial therapy. Another example would be a patient
known microalbuminuria? with CAD and angina starting on a beta-blocker as initial treat-
A) Lisinopril. ment rather than a thiazide (since the beta-blocker may improve
B) Metoprolol. angina symptoms and is indicated or CAD). Recall that not all
C) Losartan. beta-blockers are created equal. Atenolol is least pre erred and
D) Verapamil. metoprolol succinate is among the best. I the patient has renal
E) Amlodipine. disease, consider an ACE inhibitor as rst-line treatment or
Answer 2.15.9 The correct answer is “A.” In a diabetic patient
who has proteinuria, an ACE inhibitor is indicated to slow down
the progression o renal disease. An ARB or nondihydropyridine HELPFUL (AND IMPORTANT) TIP:
CCB (verapamil, diltiazem) are viable alternatives or those who Beta-b cke s have a en ut av as a st- ne
cannot tolerate an ACE inhibitor. (Note: Some elderly patients ch ce h pe tens n. The d n’t seem t c n e as
may not tolerate verapamil or diltiazem due to bradycardia or much su v va bene t as the ant h pe tens ve c asses.
may not be candidates due to LV systolic dys unction). However, The ne except n s n pat ents w th CAD CHF.
ACE inhibitors are still rst line. T ese recommendations stem
rom the renal and cardiac bene ts o ACE inhibitors.

HELPFUL TIP: Remember the 35-year-old guy? You start him on chlortha-
A th ugh th az de d u et cs dec ease the e t vent cu a lidone, but his blood pressure does not respond at a dose o
d amete (due t d u es s), beta-b cke s, CCBs, and ACE 12.5 mg/day (have your patients cut the 25-mg tabs in hal ).
nh b t s all eve se l VH. His blood pressure on ollow up is 148/96 mm Hg.

Question 2.15.11 The best approach or such a patient is to:

HELPFUL TIP: A) Push his chlorthalidone to 25 mg daily be ore starting
Expe ts (and the te atu e) g back and th between another medication.
ch s ng the d standb , h d ch th az de (HCTZ), B) Stop the chlorthalidone and start another medication.
and the even de d ug, ch tha d ne. H p ka em a C) Rely on exercise and diet to normalize the blood pressure.
s m e equent seen w th ch tha d ne than w th D) Start a second drug be ore you have maximized the dose o
HCTZ. P tass um sh u d be m n t ed pe d ca w th the rst drug.
d u et cs an wa , and h p ka em a ten c mp cates E) Start a work-up or secondary causes o hypertension.
h pe tens n. F) A or D.

Answer 2.15.11 The correct answer is “F.” Per the JNC 8

Question 2.15.10 Digressing a bit urther . . . Which o the guidelines, both “A” and “D” are acceptable strategies; you
ollowing drugs might you want to use6 as your initial could push up the dose o a rst drug or add a second drug.
agent or the treatment o hypertension in a 72 year old T ere is a lack o randomized controlled trials to guide these
male who you also diagnosed with symptomatic benign recommendations. JNC 8 urges us to tailor therapy based on
prostatic hypertrophy? individual circumstances, clinician and patient pre erence, and
A) Amlodipine. drug tolerability. Low-dose chlorthalidone (12.5 mg) provides
B) Doxazosin. the greatest blood pressure reduction per mg o drug, and
C) Captopril. there is little clinical bene t o utilizing >25 mg daily o HC Z
D) Losartan. or chlorthalidone. Higher doses are associated with increased
E) Verapamil. adverse e ects with minimal clinical gain in hypertension
CHAPTER 2 • CAr Dio l o Gy 75

management. “B” is incorrect because a patient with this level TABLE 2-8 CAUSES OF SECONDARY HYPERTENSION
o blood pressure elevation will generally require more than
D ugs, nc ud ng ve -the-c unte med cat ns
one drug to achieve a normalized blood pressure. “C” is incor-
S eep apnea
rect because the majority o patients are unable to maintain
an adequate diet or exercise regimen to e ectively treat blood End c ne:
• H pe a d ste n sm
pressure. Exercise and dietary change are certainly laudable • Phe ch m c t ma
goals and should be encouraged in all patients. However, they • Th d d sease
are not likely to normalize blood pressure in most hyperten- • Cush ng s nd me ( nnate at gen c)
sive patients. “D” is also correct as it represents one o the Vascu a :
acceptable JNC 8 guideline strategies to dose antihypertensive • r ena a te sten s s
drugs. “E” is incorrect since this patient has not yet proven to • C a ctat n the a ta
be resistant to treatment. int ns c ena d sease

HELPFUL TIP: to control hypertension. Secondary causes o hypertension

An the st ateg the n t a t eatment h pe ten- include: hyperaldosteronism, RAS, pheochromocytoma, Cush-
s n, depend ng n the pat ent’s b d p essu e, s t ing disease, untreated obstructive sleep apnea, primary hyper-
sta t the ap w th tw d ugs at submax ma d ses (e.g., parathyroidism, medications (OCP), and others. “A” is the thing
s n p 10 mg and HCTZ 12.5 mg), ec gn z ng that to avoid because when checking the serum potassium level or
m st pat ents w eventua need tw d ugs. hyperaldosteronism, the patient must be o all diuretic medi-
cations and have an unrestricted salt intake. All o the others
choices can be a part o a work-up or secondary hypertension
You decide to start this patient on diltiazem as a second agent. caused by RAS (“B”), Cushing disease (“C”), and pheochromo-
cytoma (“D”), respectively (see able 2-8).
Question 2.15.12 Which o the ollowing side ef ects is most
characteristic o diltiazem and other CCBs? Question 2.15.14 You decide to check this patient or RAS.
A) Dehydration. The best choice or a screening test or RAS is:
B) Cough. A) Doppler ultrasound.
C) Dependent edema. B) Captopril renal scan.
D) Hypokalemia. C) Serum renin level.
E) Elevated cholesterol. D) MR or C angiography.
E) Both A and D.
Answer 2.15.12 The correct answer is “C.” As a class, CCBs
tend to cause peripheral edema. Dehydration and hypoka- Answer 2.15.14 The correct answer is “E.” Per the ACC/AHA
lemia can be caused by diuretics. Cough and hyperkalemia guideline or diagnosing RAS, duplex ultrasonography, C A
are characteristic o ACE inhibitors and ARBs. Diuretics in patients with normal renal unction, and MRA are the rec-
can increase cholesterol, while beta-blockers can increase ommended screening tools or diagnosis o RAS (Class I Level
triglycerides. o Evidence B). T e captopril renal scintigraphy, selective renal
vein renin measurements, plasma renin activity and the cap-
Despite the act that the patient is on two medications, he topril test (which includes measurement o plasma renin lev-
remains hypertensive. In act, the blood pressure has barely els at baseline and a er captopril administration) are consider
moved. With your thorough history taking, you have ruled Class III or screening tests or establishing the diagnosis o
out excess alcohol intake (o en an “occult” cause o hyper- RAS.
tension). T e patient is compliant with his medications.

Question 2.15.13 Further investigations that might be HELPFUL TIP:

help ul in determining the cause o hypertension in this C ns de an eva uat n r AS n a pat ent wh has a
patient include all o the ollowing EXCEPT: “p s t ve” c n ca ( nadve tent) “capt p cha enge.” i
A) Checking the potassium level while the patient is taking his u sta t an ACE nh b t and see a d amat c dec ne
current medications to rule out hyperaldosteronism. n ena unct n n a ew da s, r AS, espec a b ate a
B) Assessing or renal artery stenosis (RAS). r AS, ma be the cu p t.
C) Checking a 24-hour urine or glucocorticoids.
D) Checking a 24-hour urine or catecholamines.
Your patient does not have any identi able cause or second-
Answer 2.15.13 The correct answer is “A.” Hypertension is ary hypertension. You add a third agent, and his blood pres-
secondary to another cause in about 1% o patients with mild sure comes under control. Sometimes, you just have to be
hypertension but in 10% to 45% o those with severe, di cult persistent!
76 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW

Question 2.16.2 Which o the ollowing is true?

A) Many patients with hyperaldosteronism have normal serum
Add ng sp n act ne t the eg men a pat ent
w th d cu t t c nt b d p essu e can ten
B) In hyperaldosteronism, the plasma aldosterone-to-renin
be he p u even n the p esence an the d u et c.
ratio is usually high.
Watch h pe ka em a when sp n act ne s used
C) All antihypertensives should be stopped be ore checking a
w th ACE nh b t s. Ep e en ne s an acceptab e
plasma renin level.
a te nat ve.
D) I a con rmatory 24-hour urine is done, the urine potassium
should be low to con rm the diagnosis o hyperaldosteronism.
Objectives: Did you learn to . . . E) A and B.
• Eva uate a pat ent w th n t a h gh b d p essu e ead ngs?
• Se ect n t a ant h pe tens ve the ap ?
Answer 2.16.2 The correct answer is “E.” Many patients with
hyperaldosteronism will have normal serum potassium levels.
• App p ate ta the t eatment h pe tens n, based n
pat ent-spec c cha acte st cs?
In addition, the plasma aldosterone-to-renin level is usually
high. “C” is incorrect because, although ACE inhibitors and
• Use and nte p et 24-h u ambu at b d p essu e m n -
t ng?
spironolactone (and perhaps all diuretics) should be stopped
be ore renin and aldosterone levels are drawn, other antihy-
• Unde stand the c ncept wh te c at h pe tens n?
pertensives (e.g., CCBs) will have little e ect on plasma renin
• Gene ate a d f e ent a d agn s s and an app p ate eva ua-
levels. “D” is incorrect because hyperaldosteronism causes
t n sec nda h pe tens n?
potassium wasting, so the urine potassium should be elevated.

You diagnose this patient with hyperaldosteronism.

CASE 2.16
You have a patient who is mildly hypertensive and decide Question 2.16.3 The most common cause o hyperaldoste
to check baseline labs. On no medications whatsoever, the ronism is:
patient’s potassium is low at 3.0 mEq/L. You re-check the A) Adrenal adenoma.
potassium be ore getting too excited. It is 2.9 mEq/L. B) Idiopathic.
C) Pituitary adenoma.
Question 2.16.1 O the ollowing, the MOST LIKELY cause D) Aldosterone-secreting tumor such as small-cell carcinoma.
o low potassium in this patient is: E) RAS.
A) Hyperaldosteronism.
Answer 2.16.3 The correct answer is “A.” Adrenal adenomas
B) Hypoaldosteronism.
are the most common cause o hyperaldosteronism. T e second
C) Spuriously low potassium because o an elevated glucose.
leading cause is idiopathic.
D) Metabolic acidosis.
Question 2.16.4 Accepted approaches to the treatment o
Answer 2.16.1 The correct answer is “A.” Hyperaldosteron- hypertension caused by hyperaldosteronism include all o
ism can cause hypokalemia and hypertension. Aldosterone the ollowing EXCEPT:
increases the secretion o potassium, which leads to hypokale- A) Unilateral adrenalectomy in the case o adrenal adenoma.
mia. “B” is incorrect because hypoaldosteronism, such as that B) Liberalized sodium intake.
seen with adrenal ailure secondary to adrenal destruction, C) Use o a potassium-sparing diuretic.
causes hyperkalemia and hypotension. “C” is incorrect because D) Use o a combination o amiloride and H CZ.
elevated glucose does not result in a spuriously low potassium;
i you answered “C,” maybe you were thinking o sodium (the Answer 2.16.4 The correct answer is “B.” Liberalizing sodium
sodium goes down by approximately 1.6 to 2 mEq/L or every intake will actually cause volume expansion, which is counter-
100 mg/dL increase in the glucose). Finally, “D” is incorrect productive and can lead to urther hypokalemia. Once the patient
because a metabolic acidosis should cause an elevated potas- is hypervolemic, there will be a spontaneous diuresis (the so-
sium rather than a low one. called “aldosterone escape”) leading to increased hypokalemia.
T e exact mechanism o aldosterone escape is not known, but it
occurs a er a weight gain o approximately 3 kg rom f uid reten-
tion. I you want to sound smart, just say it is “neurohumeral.”
The se um p tass um g es up b app x mate
You will probably be right and it makes you sound cool.
1 mEq/l eve 0.1 dec ease n the pH m 7.4. Thus,
the p tass um w u d g m 4 t 6 mEq/l the pH Objectives: Did you learn to . . .
changes m 7.4 t 7.2. • ident ab at abn ma t es that ccu n h pe a d ste-
n sm?
• Eva uate a pat ent suspected hav ng h pe a d ste n sm?
You suspect that the patient has hyperaldosteronism. • in t ate t eatment h pe a d ste n sm?
CHAPTER 2 • CAr Dio l o Gy 77

FIGURE 2-6. r h thm st p pat ent n quest n 2.17.1.

observation as long as any underlying cardiac disease is

QUICK QUIZ: ACE iNHiBiTo r S treated. You should also stop any medications that might be
contributing to this rhythm disturbance, such as digoxin,
Which o the ollowing side e ects is/are associated with the use beta-blockers and other AV node blocking agents. Pacemaker
o ACE inhibitors? is appropriate or a ew select patients, usually those with
A) Cough. symptoms. Atropine is used in the emergent setting or treat-
B) Dependent edema. ment o bradycardia.
C) Hypokalemia.
D) Angioedema. Question 2.17.3 What is the proper diagnosis o the ECG
E) A and D. shown in Figure 2 8?
A) Anterior wall myocardial in arction.
The correct answer is “E.” Both chronic dry cough and angio- B) Posterior wall myocardial in arction.
edema (more common in blacks or in patients with hereditary C) Pericarditis.
angioedema) are side e ects o ACE inhibitors. Hyperkalemia D) Hyperkalemia.
is another potential concern. T ese side e ects may not occur E) In erior wall myocardial in arction (IMI).
immediately. Hence, you should be wary o these symptoms
in any patient on an ACE inhibitor or any period o time. Answer 2.17.3 The correct answer is “E.” T is is an IAMI. Note
the S elevations in leads II and III, and aVF with reciprocal
changes in leads V2–V5 (see indicator arrows in Fig. 2-9).
CASE 2.17: Rhythm Strips
Question 2.17.1 What is the rhythm on the rhythm strip A patient presents with a history o lightheadedness when he
shown in Figure 2 6? stands and has the ECG shown in Figure 2-10.
A) Second-degree heart block, type I.
B) Second-degree heart block, type II. Question 2.17.4 What is the rhythm?
C) T ird-degree heart block with junctional escape rhythm. A) Atrial f utter with 4:1 block.
D) Sinus rhythm with nonconducted PACs. B) Atrial brillation with slow ventricular response.
C) Atrial tachycardia with third-degree heart block.
Answer 2.17.1 The correct answer is “A.” T is is a Wenckebach D) Mobitz type I (Wenckebach).
block, also known as second-degree heart block type I or Mob-
itz type I AV block. Note the progressive prolongation o the PR Answer 2.17.4 The correct answer is “C.” T is is an atrial
interval be ore a nonconducted P wave on the rhythm strip in tachycardia with a third-degree heart block. T e P wave pre-
Figure 2-7 (arrows indicate P waves). ceding each QRS complex is indicated with an arrow on the
ECG shown in Figure 2-11. Note that there is no consistent
Question 2.17.2 The proper treatment o an asymptomatic relationship between the P waves and the QRS complexes (i.e.,
patient with this rhythm is: the PR interval varies and there is no predictability), giving the
A) reat any underlying causes identi ed and observe. diagnosis third-degree heart block.
B) Place temporary pacemaker ollowed by permanent pace-
maker. Question 2.17.5 The appropriate treatment o this patient
C) Give atropine ollowed by permanent pacemaker. with atrial tachycardia and third degree block is:
D) Re er or an electrophysiologic study. A) Pacemaker.
B) Isoproterenol.
Answer 2.17.2 The correct answer is “A.” Wenckebach/ C) Lidocaine.
second-degree heart block type I can be treated with D) Atropine.

FIGURE 2-7. A ws sh w P waves w th p g ess ve nge Pr nte va .

78 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW

FIGURE 2-8. ECG pat ent n quest n 2.17.3.

FIGURE 2-9. A ws sh w ST segment dep ess ns n ii, iii and aVF w th ec p ca dep ess ns n V2, V3 and V4.
CHAPTER 2 • CAr Dio l o Gy 79

FIGURE 2-10. ECG pat ent n quest n 2.17.4.

FIGURE 2-11. A ws sh w P waves p t each Qr S. N te the unp ed ctab e va at n n Pr nte va s.

80 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW

Answer 2.17.5 The correct answer is “A.” T e treatment o a treat the ischemia rst. I the rhythm is not causing any problem,
third-degree heart block is a pacemaker. Atropine will increase observation is good or now.
the atrial rate, but that is not the problem here. T e problem is
AV conduction. Isoproterenol will increase the ventricular rate Question 2.17.7 The rhythm shown in Figure 2 14 is best
but is arrhythmogenic and may cause hypotension. Lidocaine is described as:
not indicated in this patient. A) Atrial f utter with 2:1 block.
B) 2:1 second-degree heart block, Mobitz type II.
C) Sinus bradycardia.
At a tach ca d a w th b ck s “c ass c” d g ta s nt x-
cat n. i th s pat ent we e n d g x n, u w u d t eat Answer 2.17.7 The correct answer is “B.” T is rhythm strip
w th D g b nd. represents second-degree heart block, Mobitz type II. Notice
that the PR interval is constant and there are dropped beats (see
Question 2.17.6 The drug o choice or the rhythm in Fig. 2-15, with indicator arrows showing P waves with no asso-
Figure 2 12 is: ciated QRS complexes). T is patient needs a pacemaker.
A) Atropine.
B) Procainamide. Question 2.17.8 The electrocardiogram shown in Figure 2 16
C) Quinidine. is consistent with which o the ollowing?
D) Metoprolol. A) Pericardial e usion.
E) Lidocaine. B) Pneumothorax.
C) PE.
Answer 2.17.6 The correct answer is “D.” T is is an acceler- D) Cardiac contusion.
ated junctional rhythm that generally occurs only in the set- E) None o the above.
ting o cardiac ischemia. Note the absence o P waves. Using a
Class I antiarrhythmic can extinguish this rhythm, causing asys- Answer 2.17.8 The correct answer is “A.” T is is an example
tole (usually considered a bad outcome . . . ). T e patient also o electrical alternans. Note the low QRS voltages that alternate
has in erior wall ischemia (see Fig. 2-13, with indicator arrows in height rom beat to beat. T is type o pattern is seen with
showing depressed S segments in the in erior leads). Slowing pericardial e usion. It is a late nding and one should be very
down this rhythm with metoprolol is acceptable, but you should concerned about tamponade.

FIGURE 2-12. ECG pat ent n quest n 2.17.6.

CHAPTER 2 • CAr Dio l o Gy 81

FIGURE 2-13. Acce e ated junct na h thm; a ws sh w n e ST segment dep ess n.

Question 2.17.9 The ECG in Figure 2 17 is consistent with Objectives: Did you learn to . . .
which o the ollowing? • ident seve a t pes ca d ac a h thm as, nc ud ng hea t
A) Anterior myocardial in arction. b ck and junct na h thm?
B) Anterolateral myocardial in arction. • D agn se iMi b ECG?
C) Pericarditis. • Desc be ECG eatu es pe ca d a ef us n and pe ca d t s?
D) Early repolarization.
E) Everywhere in arction
CASE 2.18: More Rhythm Strips
Answer 2.17.9 The correct answer is “C.” his ECG is A 24-year-old emale presents to the ED with a history o
consistent with pericarditis. his ECG demonstrates several tachycardia and the rhythm strip shown in Figure 2-19. Her
indings that indicate pericarditis, including sinus tachy- blood pressure is 115/70 mm Hg with an oxygen saturation o
cardia, di use S elevations, and PR depression (see also 98%on room air. T ere are no associated symptoms o chest
Fig. 2-18). pain, dyspnea, etc.

FIGURE 2-14. r h thm st p pat ent n quest n 2.17.7.

FIGURE 2-15. Sec nd deg ee hea t b ck, M b tz t pe ii.

82 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW

FIGURE 2-16. ECG pat ent n quest n 2.17.8.

FIGURE 2-17. ECG pat ent n quest n 2.17.9.

CHAPTER 2 • CAr Dio l o Gy 83

FIGURE 2-18. ECG c ns stent w th pe ca d t s.

Question 2.18.1 The appropriate treatment o this patient is: Question 2.18.2 This ECG represents:
A) Adenosine 6 mg IV ollowed by 12 mg IV. A) Normal ECG.
B) Diltiazem 5 mg/kg IV. B) Wol –Parkinson–White (WPW) syndrome.
C) Verapamil 25 mg IV. C) RBBB.
D) Digoxin 0.5 mg IV. D) Right axis deviation.
E) De brillation. E) LVH.

Answer 2.18.1 The correct answer is “A.” T is rhythm is Answer 2.18.2 The correct answer is “B.” T is is an ECG dem-
PSV . T ere are several treatment options or PSV , which onstrating WPW pattern. When combined with documented
include adenosine, diltiazem, and verapamil. However, “B” tachyarrhythmia, it is re erred to as WPW syndrome. Note the
and “D” are incorrect because the dose or diltiazem is 0.25 short PR interval as well as the delta wave (Fig. 2-21).
mg/kg IV, not 5 mg/kg, and the dose or verapamil is 2.5 to 5
mg IV, not 25 mg IV. While cardioversion is also an option Let’s say this patient comes back to the ED with atrial brilla-
in a hemodynamically stable patient, medication should be tion in the upcoming week. T is time you suspect WPW and
tried rst. De brillation is never recommended or a per us- want to choose a rate-controlling medication.
ing rhythm.
Question 2.18.3 Which is the BEST medication choice or
You treat the patient with adenosine but there is no this patient in light o her diagnosis o WPW?
response. T us, you choose to try a CCB. Un ortunately, A) Procainamide.
the patient rapidly deteriorates with the CCB, and her B) Sotalol.
heart rate actually increases, so you success ully cardiovert C) Diltiazem.
the patient. T e ECG done a er cardioversion is shown in D) Verapamil.
Figure 2-20. E) Metoprolol.

FIGURE 2-19. r h thm st p pat ent n quest n 2.18.1.

84 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW

FIGURE 2-20. ECG pat ent n quest n 2.18.2.

FIGURE 2-21. ECG c ns stent w th W -Pa k ns n-Wh te s nd me.

CHAPTER 2 • CAr Dio l o Gy 85

FIGURE 2-22. ECG pat ent n quest n 2.18.4.

Answer 2.18.3 The correct answer choice is “A.” Patients with and aVL. Because the QRS is narrow, neither LBBB nor RBBB
WPW deteriorate with beta-blockers and CCBs (“B”–“E”). T e can be correct. Le posterior block is quite uncommon due to
drug o choice is procainamide in patients with WPW who the size o the posterior ascicle.
presents with PSV , including atrial brillation/f utter. T e
other alternative is ibutilide. T e reason is that the AV node Question 2.18.5 The ECG shown in Figure 2 23 represents
is protective since it helps block most re-entrant conductions which o the ollowing?
( or re-entrant arrhythmias that rely on the AV node). I you A) LBBB.
block the AV node with beta-blockers or CCBs, the re-entrant B) RBBB.
loop is allowed to go “wild” (just like you’ve probably seen that C) LAFB.
reality show, “Rhythms Gone Wild”). T e clues to look or to D) Le posterior ascicular block.
help identi ying patients with WPW are a young patient with E) None o the above.
previous episodes o palpitations, rapid heart rate, or syncope.
Answer 2.18.5 The correct answer is “A.” T is ECG represents
Question 2.18.4 The ECG shown in Figure 2 22 represents an LBBB. Criteria include QRS width ≥ 0.12 ms, upright (mono-
which o the ollowing? phasic) QRS in leads I and V6, and a mostly negative QRS in V1.
C) Le anterior ascicular block (LAFB). We d n’t suggest that u e n th s but . . . The r –r
D) Le posterior ascicular block. p me s n the right s de the ECG n an r BBB (V1, V2,
E) None o the above. V3). The r –r p me s n the left s de the ECG n an
l BBB ( ead i).
Answer 2.18.4 The correct answer is “C.” For those o us who
are visually challenged, any patient with a net negative orce in Question 2.18.6 The ECG shown in Figure 2 24 represents
lead II will have le axis deviation and likely le anterior as- which o the ollowing?
cicular block (LAFB) (provided proper lead placement). Also, A) First-degree block.
look or net negative def ection in leads III and aVF. For those B) RBBB.
who like the numbers, LAFB is present when the QRS axis is C) LAFB.
−45 to −90 degrees, there is an rS pattern (with small r waves) in D) All o the above.
leads II, III, and aVF and a qR pattern (with small q waves) in I E) None o the above.
86 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW

FIGURE 2-23. ECG pat ent n quest n 2.18.5.

FIGURE 2-24. ECG pat ent n quest n 2.18.6.

CHAPTER 2 • CAr Dio l o Gy 87

Answer 2.18.6 The correct answer is “D.” T is ECG represents opposite ECG ndings occur with hypokalemia. ECG ndings o
a rst-degree AV block, an RBBB, and an LAFB. T e RBBB is hypokalemia include decreased amplitude o -waves, progressing
de ned by a QRS width o ≥0.12 ms (>3 small blocks) and an to -wave inversions associated with S segment depression, ol-
rsR (“rabbit ears”) in chest leads V1–V3. T is patient also has an lowed by increased PR interval and increased P-wave amplitude.
LAFB (see the ECG in Fig. 2-22 or criteria). T e U-wave is a late and inconsistent nding o hypokalemia.

Objectives: Did you learn to . . . Question 2.19.2 All o the ollowing are potential causes o
• ident PSVT b ECG and p esc be n t a t eatment? this patient’s hyperkalemia EXCEPT:
• Desc be ECG nd ngs WPW? A) Metabolic acidosis.
• D f e ent ate between d f e ent t pes hea t b ck based n B) ACE inhibitors.
ECG nd ngs? C) ARBs.
D) Renal ailure.
CASE 2.19 E) Furosemide.

A 75-year-old patient with chronic kidney disease and diabe- Answer 2.19.2 The correct answer is “E.” Furosemide will
tes presents to your ED or chest tightness, atigue, and palpi- cause hypokalemia rather than hyperkalemia. All the other
tations, and has the ECG shown in Figure 2-25. answer choices are potential causes o hyperkalemia. Other
causes o hyperkalemia include a potassium load rom muscle
Question 2.19.1 What is the most likely electrolyte abnor breakdown (e.g., rhabdomyolysis, burns, trans usion o old
mality in this patient? blood), tumor lysis syndrome, and other exogenous sources o
A) Hypokalemia. potassium such as penicillin, potassium supplements, “lite” salt,
B) Hyperkalemia. and water so eners. Consider also Addison disease and hypoal-
C) Hyponatremia. dosteronism. Digoxin toxicity is also a possibility.
D) Hypermagnesemia.
E) Hypercalcemia. Question 2.19.3 What is the rhythm shown in Figure 2 26?
A) Atrial brillation.
Answer 2.19.1 The correct answer is “B,” hyperkalemia. Note B) Normal sinus rhythm with multiple PACs.
the peaked -waves across the precordium. Note also that the C) T ird-degree heart block with rapid rate.
patient has early repolarization. “A” is incorrect, and many o the D) Multi ocal atrial tachycardia (MA ).

FIGURE 2-25. ECG pat ent n quest n 2.19.1.

88 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW

FIGURE 2-26. ECG pat ent n quest n 2.19.3.

Answer 2.19.3 The correct answer is “D.” T is is a MA . Note Resting transcutaneous oximetry is 92% at rest. BMI is
the multiple morphologies o the P waves indicated by arrows 24 kg/m2. She has JVD but clear lungs. A grade 2/6 mid-
in Figure 2-27 as well as the irregularity o the rhythm. Here are systolic murmur is heard over the le upper sternal border.
help ul tips in diagnosing and treating MA : three or more di - Electrocardiogram is shown (Fig. 2-28).
erent P-wave morphologies with varying PR intervals. Causes
include theophylline, pulmonary disease, and abnormal electro- Question 2.20.1 What is the most likely diagnosis?
lytes (K+ or Mg). Digoxin may worsen MA ! Rarely, AV nodal A) CAD.
ablation with permanent pacing can be considered in re ractory B) Pulmonary hypertension.
cases. C) Asthma.
D) Congenital aortic stenosis.
Question 2.19.4 All o the ollowing are treatments o MAT E) Mitral valve prolapse.
A) Nondihydropyridine CCB (verapamil, diltiazem). Answer 2.20.1 The correct answer is “B.” T e physical exami-
B) Beta-blocker. nation is consistent with right ventricular pressure overload.
C) Magnesium. T is is supported by the electrocardiogram demonstrating
D) Improving pulmonary unction and reducing hypoxia. right atrial enlargement, right axis deviation, and RVH. CAD
E) Adenosine. is almost unheard o in a woman younger than 30 years with-
out any risk actors. Asthma may cause her symptom com-
Answer 2.19.4 The correct answer is “E.” All o the others are plex but is not supported by her examination. Aortic stenosis
indicated in the treatment o MA . Adenosine may slow down causes neither resting hypoxemia nor RVH. Because they have
the rhythm temporarily but is not considered a treatment o this a xed cardiac output (limited by lung vascular pressures),
rhythm. patients with pulmonary hypertension o en get presyncopal
Objectives: Did you learn to . . . with exertion.
• r ec gn ze ECG nd ngs ass c ated w th h pe ka em a and Note: Findings that suggest RVH on the ECG: right axis devi-
h p ka em a? ation, right atrial abnormality (P-wave >2.5 boxes tall in lead
• Desc be ECG nd ngs and t eatment pt ns MAT? II), RVH (tall R in V1), and strain pattern in leads II and III.
O en patients with pulmonary hypertension will have an intra-
ventricular conduction delay with R–R′ in V1 (not shown on
this electrocardiogram, Fig. 2-29).
CASE 2.20
A 28-year-old woman with no signi cant past medical his- Question 2.20.2 The ollowing tests may be help ul in eluci
tory presents to clinic with complaints o progressive short- dating the cause o pulmonary hypertension EXCEPT:
ness o breath; she becomes dyspneic with less activity than A) Chest x-ray and pulmonary unction studies.
1 year ago. I she exerts hersel beyond a brisk walk, she B) C scan.
becomes lightheaded, presyncopal, and eels tightness in her C) ANA, HIV antibody/antigen testing and liver unction studies.
chest. She also notes generalized atigue. Your examination D) Nasopharyngoscopy.
discloses a heart rate o 105 bpm and normal blood pressure. E) Polysomnogram.

FIGURE 2-27. A ws sh w P waves va ng m ph g , c ns stent w th MAT.

CHAPTER 2 • CAr Dio l o Gy 89

FIGURE 2-28. ECG pat ent n quest n 2.20.1.

Answer 2.20.2 The correct answer is “D.” An important part history and physical examination. Chest radiography and PF s
o the work-up or pulmonary hypertension is de ning the eti- can identi y chronic lung disease causing (or contributing to)
ology and potentially reversible causes. T ere is no cookbook pulmonary hypertension. A C scan is done to exclude chronic
approach, and diagnostic work-up should be tailored by the thromboembolic pulmonary disease and to evaluate or brosis,

FIGURE 2-29. ECG c ns stent w th r VH. N te a ge r wave n V1 and ght ax s dev at n.

90 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW

sarcoidosis, etc. Connective tissue disease, HIV, and cirrhosis examination, you notice that he had nodules on his ngertips
are known to cause pulmonary hypertension. Sleep apnea is an and notice a slight reddish discoloration under his ngernails.
important, treatable cause o PH N. Nasopharyngoscopy has On urther questioning, he tells you that he recently moved
no role in this work-up. here rom a major city and had used IV drugs in the very dis-
tant past, by which he means as recently as last month.
An echocardiogram con rms ndings suggestive o severe
pulmonary hypertension and changes consistent with right Question 2.21.1 Your next step in management is:
ventricular pressure overload (a right heart catheterization is A) Order a chest x-ray and start empiric levof oxacin.
required or diagnosis). No intracardiac shunt is identi ed by B) Order a chest x-ray and start empiric ce riaxone and
echo. T e remainder o her diagnostic work-up ails to identi y azithromycin.
a secondary cause o pulmonary hypertension. A right heart C) Order a chest x-ray, echocardiogram, draw blood cultures.
catheterization con rms severe pulmonary hypertension but D) Order a chest x-ray and start empiric piperacillin and vanco-
also ails to identi y a shunt. A vasodilator challenge (with ade- mycin.
nosine) is per ormed and no change in pulmonary pressure is E) Order a chest x-ray and do nothing, it is probably viral.
elicited. She is given a diagnosis o idiopathic pulmonary arte-
rial hypertension. Answer 2.21.1 The correct answer is “C.” Although the
T e treatment o pulmonary hypertension is, in general, chest x-ray is overkill or a case o endocarditis, it may iden-
very specialized and a cardiologist should be involved. Excep- ti y other causes o ever and help evaluate or heart ailure.
tions include pulmonary hypertension rom chronic hypoxia he patient is presenting with IV drug use history, Osler
(smoking, sleep apnea) that are amenable to primary care nodes, and Janeway lesions (nail-bed hemorrhages), as well
management. Chronic PE can also be managed by the primary as ever. hese easily meet three minor Duke criteria (see
care practitioner, although the patient should still ollow with able 2-9), quali ying or a “possible diagnosis o endocardi-
a cardiologist due to the potential or right heart ailure. tis.” Now what you need is one major criterion to de initively
diagnose endocarditis. A positive echocardiogram or blood
culture would quali y. Once the blood cultures are drawn, i
your suspicion is high, you may start empiric antibiotics or
Add t na the ap pu m na h pe tens n ma
nc ude p stac c n and ph sph d este ase nh b t s
(e.g., s dena , tada a , va dena ). S me pat ents e-
Question 2.21.2 Which valve(s) are most commonly af ected
qu e ant c agu at n. Management sh u d be d ected
by endocarditis?
b a pu m na h pe tens n spec a st.
A) Aortic valve.
B) Mitral valve.
C) Pulmonic valve.
D) Demonic valve.
E) A and B.
CASE 2.21
A 54-year-old male presents to your clinic complaining o dys- Answer 2.21.2 The correct answer is “E.” T e aortic and mitral
pnea and evers. His temperature in the o ce is 38.5°C and valves are most commonly a ected. T ere is no demonic valve,
heart rate is 113 bpm with pulse oximetry o 93%. On physical we hope, but there is the tricuspid, o course.

Major Criteria Minor Criteria
• Tw p s t ve b d cu tu es gan sms t p ca • P ed sp s ng hea t d s de
end ca d t s • iV d ug abuse
• Th ee p s t ve b d cu tu es gan sms c ns stent w th • Feve ≥38°C
end ca d t s • Vascu a phen mena: a te a emb sm, sept c pu m na emb sm,
• Se g c ev dence Coxiella burnetii m c t c aneu sm, nt ac an a hem hage, c njunct va petech ae,
• Ech ca d g aph c ev dence end ca d a nv vement: Janewa es ns
o sc at ng nt aca d ac mass n a hea t va ve, n supp t ng • immun g c phen mena: g me u neph t s, o s e n des, r th sp ts,
st uctu es, n the path egu g tant jets, n mp anted heumat d act
mate a w th ut an the anat m c exp anat n; ca d ac • Mc b g c ev dence n ect n c ns stent w th but n t meet ng maj
abscess; new deh scence p sthet c va ve; new va vu a c te a
egu g tat n • Se g c ev dence n ect n w th gan sms c ns stent w th end ca d t s
CHAPTER 2 • CAr Dio l o Gy 91

Question 2.21.3 Which o the ollowing organisms is most

common in acute endocarditis?
A) Staphylococcus aureus and group B streptococci. FAil Ur E SPECiAl iST?
B) Alpha-hemolytic streptococci or enterococci.
C) Enterovirus. Which o the ollowing has been shown to improve mortality in
D) Fungi. patients with systolic heart ailure (HFrEF)?
E) Elmo muppetl (can you tell we are getting tired . . . the jokes A) Valsartan + Sacubitril (Entresto).
are getting weaker). B) Ivabradine (Corlanor).
C) Azumumumab (Coregulator).
Answer 2.21.3 The correct answer is “A.” Staph and group D) A and B.
B strep are generally responsible or acute endocarditis while E) B and C.
alpha-hemolytic streptococci and enterococci are more com-
mon with subacute endocarditis. Fungi may be present in IV The correct answer is “A.” First you need to know what these
drug abusers. As to E. muppetl, it is a new species recently things are. Entresto combines an ARB plus a neprilysin inhibi-
described by us. We groveled it in Big Bird cultures. tor. Inhibiting neprilysin increases vasodilatation and sodium
loss. It has been shown to be e ective at reducing mortality rom
Objectives: Did you learn to . . . HFrEF. T is can replace an ACE inhibitor or ARB though how
• in t ate eva uat n and management bacte a it per orms against an ACE inhibitor is not known. It cannot be
end ca d t s? given with an ACE inhibitor because o the risk o angioedema.
O course you already know that an ACE inhibitor and an
ARB should not be used together . . . right?
QUICK QUIZ: yET ANo THEr HEAr T FAil Ur E Corlanor reduces heart rate without lowering BP and is only
QUESTio N (y u th ught we we e d ne) indicated in heart ailure patients who do not reach their target
heart rate with a beta-blocker. Corlanor would be added to an
Cardiac resynchronization or heart ailure is indicated in which ACE inhibitor or ARB, a beta-blocker, and aldosterone antago-
o the ollowing patients? nist. It does not replace the beta-blocker and does not improve
A) A patient who has an ejection raction o 30% and is in atrial mortality. It supplements the beta-blocker in patients with heart
brillation that is rate-controlled. rate >70 bpm a er maximizing other medications. Corlanor can
B) A patient who has an ejection raction o 30% and is in atrial also be used in patients who do not tolerate a beta-blocker. We
brillation that is not rate-controlled (say a rate o 110–115 made up “C,” though it wouldn’t surprise us to see this drug
bpm). name at some point in the uture.
C) A patient who has an ejection raction o 30% and in normal
sinus rhythm who has an LBBB.
D) A patient with an underlying arrhythmia such as PSV who
CASE 2.22
is symptomatic. A new patient presents or his annual examination and has
E) A or B. some questions about cardiovascular disease risk. He also
wants to chat about his avorite sports team (Iowa Hawk-
The correct answer is “C.” Bet we got you on this one, huh? eyes, we hope), but you gently steer him back to the matter
T e idea behind cardiac resynchronization is to put blood at hand.
into the ventricle at the optimum time or unction. T is re-
quires the atrium to be working properly. T us, “A” and “B” are Question 2.22.1 The ollowing are all considered cardiac
wrong. T e concept is to pace the atrium and then also pace risk actors when calculating target cholesterol EXCEPT:
the ventricle so that the ventricle depolarizes at the optimum A) Male > 45 years old.
moment or blood ejection a er the blood is sent to the LV B) First-degree emale relative with CAD >65 years old.
by the atrium. T is optimal blood ejection is disordered by a C) Smoking.
LBBB where depolarization o the ventricle is delayed caus- D) Hypertension.
ing a “dyssynchrony” (as it were) between the timing o atrial E) HDL cholesterol o <40 mg/dL.
unctioning and the timing o the ventricular depolarization.
Cardiac resynchronization is “only” or patients with heart ail- Answer 2.22.1 The correct answer is “B.” It should be emale
ure who are in normal sinus rhythm. So, the basic criteria or relative with CAD at <65 years o age, not >65 years o age. See
cardiac resynchronization include a QRS o >150 ms, with a able 2-10 or a listing o cardiac risk actors. Just to be com-
LBBB, a LV ejection raction o 30% or less, and sinus rhythm plete, i the patient has an HDL > 60 mg/dL, this counts as a
who have class III or class IV heart ailure (J Am Coll Cardiol. protective actor and “cancels out” one o the risk actors. Recall
2013;61(3):e6–75). It seems to improve the overall absolute that we are talking about primary prevention only here. None
survival by about 2%; it also reduces readmissions (Ann Intern o this applies to the patient who has already had a myocardial
Med. 2014;160:603). in arction.
92 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW

• F st-deg ee ma e e at ve w th CAD at age <55 st-deg ee LIPID GUIDELINES
ema e e at ve w th CAD at age <65 Qua a h gh- 1. l Dl >190 mg/dl or
• Sm k ng d se stat n. 2. HX CAD ( equ va ent) or
• HDl <40 mg/dl 3. DM age 40–79
• D abetes
• H pe tens n Qua a P ma p event n 10- ea sk s >7.5%
• Age: ma es >45, ema es >55 m de ate-d se stat n and the pat ent has an l Dl 70–189 mg/dl
• E evated l Dl (use sk ca cu at )a and age 40–75.

Qua a w- Th se wh qua a stat n but d n’t

d se stat n. t e ate h gh- m de ate-d se stat n.
T is 55-year-old gentleman says, “All my riends take a medi- Goals of Therapy
cine or cholesterol. Shouldn’t I take one too?” You are wor- 1. The primary goal is to reach the appropriate dose of statin.
ried that he is susceptible to peer pressure, but you are also 2. r educt n l Dl b 50% m base ne.
thinking about protecting him rom atherosclerotic cardio- 3. The e a e n xed l Dl g a s (such as past g a s l Dl <100 mg/dl ).
vascular disease (ASCVD). Drug Doses
1. H gh-d se stat n = at vastat n 40–80 mg suvastat n 20–40 mg.
Question 2.22.2 According to the 2013 ACC/AHA Blood 2. M de ate-d se stat n = at vastat n 10–20 mg QD, p avastat n
Cholesterol Guideline, all o the ollowing automatically 40–80 mg BiD, and suvastat n 5–10 mg QD, am ng the s.
quali y as patients who would bene t rom statin therapy a
F nd a ca d vascu a sk ca cu at at http://t s.ca d s u ce. g/
EXCEPT: ASCVD-r sk-Est mat /
A) A patient with known cardiovascular disease.
B) A 40-year-old patient with an LDL o 200 mg/dL.
C) A 55-year-old diabetic patient with an LDL o 130 mg/dL. disease (e.g., amily history, obesity) are not taken into account.
D) A 55-year-old nondiabetic patient without known cardio- T e risk calculator is a tool; you must continue to apply clinical
vascular disease whose 10-year ASCVD risk is calculated as judgment. Also, the calculator, as well as the entire guideline, is
10%. not meant to be used to manage all orms o dyslipidemias.
E) A 35-year-old smoker with hypertension.
T e patient then asks you about something he read about
Answer 2.22.2 The correct answer is “E.” T e 35-year-old “crap.” A light bulb goes of and you realize he wants to know
patient might be a candidate or a statin (HMG-CoA reductase about C-reactive protein (CRP).
inhibitor) but is not an automatic candidate based on the in or-
mation given. All other options describe patients who would Question 2.22.4 Which o the ollowing best represents the
bene t rom statin therapy according to the 2013 ACC/AHA role o CRP in cardiac disease in 2015?
guideline. T e 2013 ACC/AHA guideline relies on a risk cal- A) CRP should be measured in all patients in whom cardiac
culator or primary prevention (located online at: http://tools. disease is suspected.
cardiosource.org/ASCVD-Risk-Estimator/). See able 2-11 or B) CRP should be measured only in patients with intermediate
a summary o the 2013 cholesterol guidelines. cardiac risk actors (e.g., those with a 10-year risk o CAD o
In order to use the ASCVD risk calculator or this patient, C) CRP should be measured in patients with known heart dis-
you need to input some in ormation. ease in order to monitor inf ammation and risk.
D) CRP should be measured in low-risk (<10% risk o CAD
Question 2.22.3 Which o the ollowing actors is included in next 10 years) patients who have no known cardiac dis-
in the ACC/AHA ASCVD risk calculator? ease. An elevated CRP suggests that these patients should be
A) LDL cholesterol level. treated with a lipid-lowering therapy.
B) Serum triglyceride level. E) CRP has not been shown to be use ul and does not contrib-
C) Hb A1c. ute signi cantly to cardiac risk strati cation.
D) Systolic blood pressure.
E) Diastolic blood pressure. Answer 2.22.4 The correct answer is “E.” Although, high-
sensitivity CRP (hsCRP) was initially thought to be a possible
Answer 2.22.3 The correct answer is “D.” T e risk actors biomarker or cardiac risk assessment, it has been shown to be
included in the ASCVD risk calculator include age, sex, race, sys- o marginal bene t. T e use o hsCRP led to minimal reclassi -
tolic blood pressure, total cholesterol, HDL cholesterol, smok- cation o patients (a maximum o 11% o intermediate patients
ing status, presence or absence o diabetes, and treatment or were reclassi ed in one study). T e Class IIa recommendation
hypertension. Unlike many Caribbean resort destinations, the to use hsCRP was published by the AHA in 2003, prior to ur-
calculator is not all-inclusive. Many known risk actors or heart ther studies that have questioned its use ulness.
CHAPTER 2 • CAr Dio l o Gy 93

2013 ACC/AHA guideline has changed the way we determine

risk, expanding the use o statins. Patients whose 10-year
We d n t use hsCr P. H weve , t we e use u , t w u d
ASCVD risk is 7.5% or greater should be on moderate-to-high-
be n the nte med ate- sk pat ents.
intensity statin therapy.

Question 2.22.7 Your astute patient appears to be goal

Per the ACC/AHA guideline, you recommend assessing his oriented and asks you what his target LDL should be. You
lipid pro le. reply:
A) “ argets are so 2012. T e goal is to get you on a moderate-
Question 2.22.5 Well, what does the USPSTF recommend to-high-intensity statin. T ere is no speci c LDL goal.”
or screening or lipid disorders? B) “Your target LDL is <100 mg/dL.”
A) Screen all adults annually starting at age 25. C) “Your target LDL is about 70 mg/dL.”
B) Screen men age 35 years and older. D) “Your target LDL is simply as low as we can get without
C) Screen women age 35 years and older. causing rhabdomyolysis . . . . Well, maybe just a little rhabdo
D) Screen all patients age 25 years and older whose BMI is will be OK.”
>25 kg/m 2.
Answer 2.22.7 The correct answer is “A.” T e 2013 ACC/AHA
Answer 2.22.5 The correct answer is “B.” As o the writing o guideline does not recommend treating to speci c LDL targets.
this book, the USPS F is in the process o updating the screen- Instead, appropriate statin therapy should be selected based
ing recommendation or lipid disorders. Published in 2008, the on risk category as previously indicated. Your goal is to get the
USPS F gave a “grade A” recommendation or screening or patient to a maximal dose o statin and not a speci c LDL. T at
lipid disorders in two groups: (1) men 35 years o age and older said, the LDL should be reduced by 50% even i that is a starting
and (2) women 45 years o age and older at increased risk or point o 400 mg/dL and the patient ends up at 200 mg/dL.
T e USPS F gave a “grade B” recommendation or (1) men
age 20 to 35 years at increased risk or ASCVD and (2) women HELPFUL TIP:
age 20 to 45 years at increased risk or ASCVD. BMI > 25 kg/m 2. The e s n ev dence that “t t at ng up” the d se a
For the purposes o the recommendation, the USPS F con- stat n s necessa he p u n p event ng s de e ects.
siders the ollowing to be signi cant risk actors: personal his- Just sta t the na app p ate d se a stat n n da 1
tory o ASCVD, diabetes, amily history o CAD be ore age 50 t eatment.
in male relative and be ore age 60 in emale relatives, tobacco
use, hypertension and obesity (BMI > 30 kg/m 2). “A” is wrong
because the USPS F does not speci y the optimal screening You advise your patient to start atorvastatin 20 mg daily.
interval. You check baseline transaminases, which are normal. When
your patient returns 3 months later and sees your partner
T e next day, you obtain asting labs. T e patient has normal (because you took a “vacation” to study or the board exami-
electrolytes and the ollowing cholesterol panel: total choles- nation), she checks his lipids and transaminases out o habit.
terol 175 mg/dL, LDL 110 mg/dL, HDL 35 mg/dL, triglycer- I only you had been there! You know that the FDA no longer
ides 150 mg/dL. He is a 55-year-old A rican-American male, recommends periodic liver enzyme testing while on a statin.
nonsmoker, and nondiabetic who takes no medications. His Statin-related hepatotoxicity is an idiosyncratic reaction
systolic blood pressure is 132 mm Hg. You plug all these that is extremely rare and completely unpredictable, so there
data into the ASCVD risk calculator and generate a 10-year is no point in routinely checking transaminases. Well, your
ASCVD risk o 7.5%. partner didn’t get the memo, and you return to nd your
patient’s AL and AS have both doubled while on atorv-
Question 2.22.6 Given the ASCVD risk you calculated, and astatin and are now almost twice the upper limit o normal
being consistent with the 2013 ACC/AHA guideline, you or your lab.
A) No changes. Keep calm and carry on. Question 2.22.8 When you nd transaminases are twice
B) A treadmill stress test. the upper limit o normal while on a statin, the proper
C) A high ber diet. response is to:
D) Low-intensity statin therapy (e.g., simvastatin 10 mg daily). A) Stop the statin because o the elevated liver enzymes.
E) Moderate-to-high-intensity statin therapy (e.g., atorvastatin B) Start a di erent statin since this is not a “class e ect.”
20–40 mg daily). C) Continue the statin and consider other causes or the ele-
vated liver enzymes.
Answer 2.22.6 The correct answer is “E.” Did you think this D) Add cholestyramine to help ease the burden on the liver.
patient was a candidate or moderate-to-high-intensity statin E) Re er or liver biopsy to rule out other causes o elevated
therapy prior to this guideline? I not, you are not alone. T e liver enzymes.
94 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW

Answer 2.22.8 The correct answer is “C.” Statins can be contin- B) His atigue and aches are a mani estation o depression and
ued as long as the elevation o liver enzymes is less than three sleep disturbance.
times the upper limit o normal. Never assume that this is a C) You can sa ely increase the dose o his statin.
drug e ect i there is a reason to believe that the patient could D) He still may have statin-induced myopathy despite a normal
have another disease, such as hepatitis C. CPK.
You are compelled to per orm the requisite history and E) Your lab has a serious quality control issue.
physical examination to assess or other causes o liver dis-
ease. In the course o your investigations, other labs and Answer 2.22.10 The correct answer is “D.” He still may
imaging may be in order. However, liver biopsy (“E”) would have statin-induced myopathy despite a normal CPK, so “A”
be taking your duciary duty to the extreme. “A” is incorrect is incorrect. T ere are several crossover trials that demon-
since the levels are only two times the upper limit o nor- strate myopathy in patients with normal muscle enzymes. T e
mal. “B” is incorrect or two reasons. First, there is no need mechanism is thought to be a mitochondrial dys unction. “B”
to act to change the drug at this point. Second, elevated liver is incorrect, and the reverse may actually be true (myopathy
enzymes are a class ef ect. “D” is incorrect because you do not causing poor sleep and anhedonia). “C” is incorrect because
need to add another drug at this time, and cholestyramine he may indeed have a myopathy, and a trial o one or both
will do nothing to “ease the burden on the liver,” whatever drugs is warranted. Remember that gem brozil (and less so
that means. eno brate), which you might prescribe or hypertriglyceride-
mia, interact with statins to increase the risk o statin-induced
A er a thorough history, examination, appropriate lab and myopathy/rhabdomyolysis. Remember also that there is no evi-
imaging tests, you determine that the liver enzyme elevation dence treating with gem brozil or eno brate improves cardio-
was due to atty in ltration. A month later the enzymes have vascular outcomes.
come down to the upper limits o normal. When you see your
patient back, he complains o pain and tenderness in his legs, You stop his atorvastatin. A ew weeks later, he returns and
shoulders and back. He also reports generalized atigue and eels great! You consider starting a dif erent agent to treat his
weakness. lipids.

Question 2.22.9 What is the most appropriate next step in Question 2.22.11 Which o the ollowing is classi ed as a
the evaluation and management o this complaint? bile acid sequestrant?
A) Stop his atorvastatin and replace it with rosuvastatin. A) Ezetimibe.
B) Double the dose o atorvastatin. B) Colestipol.
C) Check liver enzymes. C) Colesevelam.
D) Check CPK. D) B and C.
E) Start coenzyme-Q10 (ubiquinone). E) All o the above.

Answer 2.22.9 The correct answer is “D.” T is patient is pre- Answer 2.22.11 The correct answer is “D.” Ezetimibe (Zetia)
senting with symptoms that may be attributable to statin-induced is not a bile acid sequestrant but rather reduces cholesterol
myopathy. Statins have been associated with myalgia and rhab- absorption by blocking at the brush border o the small intes-
domyolysis. Prior to making any decisions about therapy, the tine. T is is a mechanism that is di erent rom any o the other
next step would be to con rm your suspicions by checking the lipid-lowering agents. It is relatively sa e but expensive and less
CPK level. I this patient has statin-induced muscle symptoms, potent than the statins.
he is unlikely to improve by switching to rosuvastatin (“A”) and
increasing the stating dose (“B”) is the wrong thing to do. While
it may be reasonable to check liver enzymes (“C”) due to his HELPFUL RANT:
complaint o atigue, myopathy is more likely given his constel- D n’t ee b gated t “just d s meth ng.” There is no
lation o symptoms. O course, in your real medical practice, you data suggesting any anti-lipid drugs other than the
could order liver enzymes and CPK, but an examination is not statins reduce cardiovascular outcomes. Some, such
real li e! Finally, “E” is incorrect. Coenzyme Q10 has not been as niacin, may actually worsen outcomes.
shown to prevent or treat statin related myopathy (Mayo Clin
Proc. 2015;90:24).
You nd yoursel staring out the examination room window,
You check a CPK level, and it is . . . normal. Darn. You thought ruminating on cholesterol medications.
you had this mystery wrapped up.
Question 2.22.12 Side ef ects o ezetimibe include which
Question 2.22.10 From this normal CPK, you can conclude o the ollowing?
that: A) Diarrhea.
A) He does not have statin-induced myopathy since the CPK is B) Arthralgia.
within normal limits. C) Angioedema.
CHAPTER 2 • CAr Dio l o Gy 95

D) Liver enzyme elevation.

E) All o the above. Clinical Pearls
A a se-p s t ve t p n n can be caused b a PE, hea t a u e,
Answer 2.22.12 The correct answer is “E.” “C” deserves spe- bu ns, seps s, st ke, and m e.
cial mention. As with ACE inhibitors, angioedema has been
A n ma ECG du ng chest pa n d es n t u e ut ACS. in
reported with the use o ezetimibe during postmarketing
act, 10% pat ents w th an Mi w have an n t a n ma
research. T e rate o occurrence is not known. However, it can ECG w th pa n.
be li e-threatening although no deaths have been reported to
Agg ess ve b d p essu e we ng n pat ents w th d abetes
date. All o the other side e ects are known to occur at a rate
ma be ha m u . Use the same g a as a m st eve ne
greater than with placebo.
e se, <140/90. The JNC 8 ep t suggests a g a <150/90 n
th se 60 ea s age and de .
Av d the c mb nat n a stat n and gem b z en -
HELPFUL TIP: b ate; t can cause habd m s s. The sk s we w th
Ev dence ezet m be s weak, nc ud ng a much- en b ate, h weve .
t uted 2015 stud (N Eng J Med 2015;372:2387). F st,
D n t c nt nue n nasp n ant p ate et agents (e.g., c p d -
the stud s awed and ks at a ve na w g up g e ) nde n te a te stent p acement. Dete m ne a ta get
pat ents (th se h sp ta zed w th kn wn CAD, the e e end date (e.g., 1 ea dua asp n-c p d g e a te p ace-
sec nda p event n). it sa s n th ng ab ut p ma ment a DES).
p event n. Sec nd, man the pat ents we e n t
D n td ut ne st ess test ng as mpt mat c pat ents
even n a stat n, the standa d ca e. F na , u have p e pe at ve . in act, d n’t pe m st ess-test ng n an
t t eat 50 pat ents 7 ea s t p event ne ca d - as mpt mat c pat ents.
vascu a event—n t a g w ng end sement, espec a
D n t use beta-b cke s a ne as ant h pe tens ve the ap
s nce the we en’t n a stat n.
un ess the e s an the nd cat n (e.g., p st-Mi, hea t a u e).
D n t use hsCr P t assess ca d ac sk.
D n t use n nstat n d ugs t we ca d ac sk n pat ents.
Metamuc the ps um p ducts a e use u n e- i us ng a beta-b cke p e pe at ve t educe ca d ac sk,
sta t t we n advance the su ge and get the pat ent n
duc ng se um ch este and p v de a “n nd ug” a -
a stab e d se be e su ge .
te nat ve. H weve , at east 7 g s ub e be da s
equ ed. Pe m an ech ca d g am when c ns de ng the d agn s s
hea t a u e. it w d e ent ate s st c hea t a u e m
d ast c hea t a u e.
Pe m ECG and adm n ste asp n 325 mg mmed ate
HELPFUL TIP: t a pat ents p esent ng w th s mpt ms m ca d a
Can’t u gu s eave ch este beh nd a ead ? N . The n a ct n.
new k ds n the b ck a e the PCSK9 (p p te n c n-
P esc be ACE nh b t s ve Ar Bs n pat ents w th h pe ten-
ve tase subt s n kex n t pe 9 nh b t s), wh ch p event
s n, ca d vascu a d sease and/ ch n c k dne d sease.
the b nd ng and the deg ad ng l Dl ecept s. S ,
the e a e m e ecept s ava ab e t em ve l Dl m P esc be stat ns a pat ents w th a h st CAD. The
2013 ACC/AHA gu de ne e m nated an l Dl g a . The g a
the b d. The st tw a e Praluent (a cumab)
s t use h gh-d se stat ns n th se wh a e h gh sk (e.g.,
and Repatha (ev cumab). The a e wa expens ve
h st m ca d a n a ct n).
($10,000/ ea ), a e njectab e, and have No utc me
data (l Dl s a su gate ma ke , c u se . . . we ca e St p a NSAiDs (except asp n) when adm tt ng a pat ent
p ss b e ACS. NSAiDs nc ease ca d ac sk.
h w the pat ent s d ng and n t the eve l Dl . Th s
has been made abundant c ea ). The a e a s n Use the CHA2-DS2-VASC sc e when dete m n ng the need
used n pat ents wh have ess than a 50% l Dl educ- ant c agu at n n at a b at n. W men w th a sc e 2
t n w th stat ns and the d ugs. and men w th a sc e 1 a e cand dates ant c agu at n.

Objectives: Did you learn to . . .
Adan V, Crown LA. Diagnosis and treatment o sick sinus syn-
• Dete m ne sk act s ASCVD? drome. Am Fam Physician. 2003;67(8):1725–1732.
• l st the sc een ng ec mmendat ns p d d s de s? Amsterdam EA, et al. 2014 AHA/ACC Guideline or the man-
• Desc be the e p d- we ng the ap n the p event n agement o patients with non–S -elevation acute coronary
ca d ac d sease? syndromes: A report o the American College o Cardiol-
• ident s me the p tent a s de ef ects p d- we ng ogy/American Heart Association ask Force on Practice
med cat ns? Guidelines. J Am Coll Cardiol. 2014;64(24):e139–e228.
96 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW

Body R, et al. Do risk actors or chronic coronary heart the Panel Members Appointed to the Eighth Joint National
disease help diagnose acute myocardial in arction in the Committee (JNC 8). JAMA. 2014;311(5):507–520.
emergency department. Ann Emerg Med. 2007;49:145. January C , et al. 2014 AHA/ACC/HRS Guideline or the
Catella-Lawson F, et al. Cyclooxygenase inhibitors and the Management o Patients With Atrial Fibrillation: Execu-
antiplatelet e ects o aspirin. N Engl J Med. 2001;345(25): tive Summary: A Report o the American College o
1809–1817. Cardiology/American Heart Association ask Force on
Dahlo B, et al. Reversal o le ventricular hypertrophy in Practice Guidelines and the Heart Rhythm Society. J Am
hypertensive patients. A meta-analysis o 109 treatment Coll Cardiol. 2014;64(21):2246–2280.
studies. Am J Hypertens. 1992;5(2):95–110. Laussen PC. Neonates with congenital heart disease. Curr Opin
Eagle KA, et al. Perioperative cardiac evaluation or noncardiac Pediatr. 2001;13(3):220–226.
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guidelines/perio/update/periupdate index.htm. disease in the adult. Cardiol Rev. 2001;9(5):276–281.
Elkayam U. Pregnancy and cardiovascular disease. Braunwald’s Nishimura RA, et al. 2014 AHA/ACC Guideline or the
Heart Disease: A extbook o Cardiovascular Medicine. Management o Patients With Valvular Heart Disease: A
Philadelphia, PA: Saunders, 2005. Report o the American College o Cardiology/American
Fihn SD, et al. 2012 ACCF/AHA/ACP/AA S/PCNA/SCAI/ Heart Association ask Force on Practice Guidelines.
S S Guideline or the Diagnosis and Management o J Am Coll Cardiol. 2014;63(22):e57–e185.
Patients with Stable Ischemic Heart Disease: a report o O’Gara P et al. 2013 ACCF/AHA Guideline or the Manage-
the American College o Cardiology Foundation/Ameri- ment o S -Elevation Myocardial In arction: A Report o
can Heart Association ask Force on Practice Guide- the American College o Cardiology Foundation/Ameri-
lines, and the American College o Physicians, American can Heart Association ask Force on Practice Guidelines.
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Gibbons RJ, et al. Management o patients with chronic stable e ects o enalapril compared with hydralazine plus isosorbide
angina update. Available at: http://www.acc.org/clinical/ dinitrate on quality o li e. V-HeF II. T e V-HeF VA Co-
guidelines/stable/update_index.htm. operative Studies Group. Circulation. 1993:87(6, Suppl):
Goyle KK, Walling AD. Diagnosing pericarditis. Am Fam VI71–VI77.
Physician. 2002;66(9):1695–1702. Stone NJ, et al. 2013 ACC/AHA guideline on the treatment o
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R h R. B r
note, there is a strong association between OD S and devel-
CASE 3.1 opment o chronic bronchitis.
A 42-year-old male who works in a hog con nement area
presents to your o ce complaining o cough, ever, wheeze, Question 3.1.2 Appropriate treatment or this patient
and dyspnea. He and some other workers were cleaning the includes:
con nement area with high-pressure hoses (which aerosol- A) Antibiotics.
ized hog waste), and they all developed the same symptoms, B) Intubation and mechanical ventilation.
which started between 4 and 8 hours a er work. On examina- C) Supportive care.
tion, he is ebrile with a respiratory rate o 28. He is able to D) A and B.
talk in complete sentences. T ere are slight crackles when you E) A and C.
auscultate the lungs. His chest x-ray is normal.
Answer 3.1.2 The correct answer is “C.” Supportive care is the
usual treatment o OD S. Antibiotics are not needed because
Question 3.1.1 The most likely diagnosis is:
the syndrome is mediated by endotoxins rather than direct
A) “Farmer’s lung” (hypersensitivity pneumonitis).
in ection. “B” is incorrect because this patient is not in signi -
B) Organic dust toxicity syndrome.
cant respiratory distress.
C) Reactive airway disease.
D) Hydrogen sul de poisoning.
E) Bronchiolitis obliterans. HELPFUL TIP:
R b r h h r rk p s r s s r,
Answer 3.1.1 The correct answer is “B.” Organic dust tox- “ r” ( br b h h
icity syndrome (OD S) occurs when moldy or decomposed k, r s s h k r r h
hay and other organic material (such as hog manure) is h rk k) s b z .
moved. Endotoxins are aerosolized and inhaled, leading to
the symptoms. T e tip o here is that everyone on the job site
was a ected. Since hypersensitivity pneumonitis (“A”) is spe-
Keep reading to get to the objectives or this case.
ci c to the individual, generally only one worker at the site
will have symptoms. Compared with OD S, hypersensitivity
pneumonitis may present with an abnormal chest x-ray with
micronodular or reticular opacities. “C” is incorrect because
CASE 3.2
everyone is involved and ebrile, which is not consistent with T is patient’s brother, who also works on a arm, notes that
reactive airway disease. “D” is not correct. Hydrogen sul de every time he unloads hay he has ever, cough, dyspnea, and
poisoning presents as a toxic pneumonitis with pulmonary sputum production. It tends to resolve in 2 to 5 days but reoc-
edema, dyspnea, hypoxia, and loss o consciousness. Hydro- curs when he is re-exposed to hay. Does he wear a mask? Well,
gen sul de also acts as a direct cellular toxin that binds to no. He would look silly and the guys would poke un at him.
cytochrome oxidase system, similar to cyanide. In addition, Besides, none o the other workers on the arm are a ected, and
hydrogen sul de exposure comes rom cleaning manure pits they are beginning to wonder i he is malingering. His examina-
(as anyone in Iowa would know). Finally, “E,” bronchiolitis tion reveals tachypnea and ne rales. T ere is no wheezing pres-
obliterans, is a chronic illness rather than an acute one. O ent. A chest radiograph shows bilateral interstitial opacities.

98 Fa mil y med ic in e exa min a t io n & Bo a Rd Review

Question 3.2.1 The most likely cause o this patient’s symp Question 3.2.4 Further evaluation will most likely reveal:
toms is: A) Bronchogenic carcinoma.
A) T ermoactinomyces candidus (an actinomyces species). B) Air space disease (e.g., a pneumonia-like picture).
B) . sacchari. C) Decreased carbon monoxide di using capacity (decreased
C) Botrytis cinerea. DLCO).
D) Cryptostroma corticale. D) Markedly abnormal bronchoalveolar lavage (BAL) with
E) None o the above. lymphocytosis.
E) Obstructive changes on pulmonary unction testing.
Answer 3.2.1 The correct answer is “A.” T is patient pres-
ents with classic symptoms o hypersensitivity pneumonitis Answer 3.2.4 The correct answer is “C.” Hypersensitivity pneu-
or, in this case, “Farmer’s lung.” T is is caused by exposure to monitis can become chronic i exposure is not limited. In these
the Actinomyces species. Acute ndings include ever, chills, cases, patients will generally have systemic complaints such as
cough, dyspnea, and chest tightness. Occasionally, the radio- atigue and possibly weight loss; ever will be absent. Dyspnea
graph is normal. High-resolution chest computed tomography and clubbing o the ngers are also generally noted, re ecting
(C ) should then be obtained, which commonly shows cen- chronic pulmonary disease. Along with this nding, pulmonary
trilobular micronodules and ground-glass opaci cation. “B,” . brosis can occur and the DLCO may be decreased. “A” is incor-
sacchari, is involved in hypersensitivity pneumonitis rom sug- rect. Hypersensitivity pneumonitis does not lead to lung cancer.
arcane (so-called Bagassosis). “C,” Botrytis cinerea, is involved “B” is incorrect. While acute hypersensitivity pneumonitis causes
in hypersensitivity pneumonitis rom grapes (so-called Spat- an alveolitis, chronic hypersensitivity pneumonitis causes pul-
lese lung). Finally, “D,” Cryptostroma corticale, is involved in monary brosis with an occasional micronodular pattern. “D”
“Maple bark stripper’s lung,” another type o hypersensitivity is incorrect. BAL in chronic hypersensitivity pneumonitis does
pneumonitis. not contain the markedly elevated lymphocyte count that is seen
with acute hypersensitivity pneumonitis. Finally, “E” is incorrect.
Question 3.2.2 The correct treatment or this patient with One would see a restrictive pattern on pulmonary unction test-
Farmer’s lung includes: ing re ecting the brosis and not an obstructive pattern.
A) Antibiotics.
B) Inhaled steroids. HELPFUL TIP:
C) Oral steroids. i h p hr rr “p ,” -
D) Leukotriene inhibitors. s r h p rs s p s. i h s s s
E) Bronchoalveolar lavage (BAL). r , s p h p 25%
s s.
Answer 3.2.2 The correct answer is “C.” Oral steroids are e ec-
tive in the treatment o hypersensitivity pneumonitis. Neither
Objectives: Did you learn to . . .
antibiotics (“A”) nor inhaled steroids (“B”) are o any bene t.
• R z h pr s s o dt S h p rs s-
“E,” bronchoalveolar lavage, is not a treatment. However, it can
p s?
be used as a diagnostic tool. One would expect to see lympho-
• m p s h s s r r r
cytes on BAL.
p s r s?

Question 3.2.3 You would advise this patient to:

A) Get a new job. QUICK QUIZ: a St Hma
B) Apply or disability.
C) Use a respirator at work and avoid exposure to this toxin i All o the ollowing populations are at increased risk or devel-
possible. oping asthma EXCEP :
D) Sue the employer. A) Obese children.
E) ake up worm arming or monoculture in rhubarb. B) Female children.
C) Children exposed to tobacco.
Answer 3.2.3 The correct answer is “C.” Wearing an appropri- D) Children with atopy.
ate respirator at work can be bene cial. Avoiding exposure is E) City children.
even better. As or the other answers, you are a doctor not a
lawyer or career counselor. Stick with what you know! The correct answer is “B.” Male children have a greater prev-
alence o asthma. Interestingly, adult women “catch up” so
T e patient is unable to change jobs or wear a respirator that there is gender equity in young adulthood. A er age 40,
because it itches and he “keeps orgetting it.” But he’s per- the prevalence is higher in emales. O note, requent respira-
sistent (or brave or thickheaded or unable to learn a new tory in ections seem to be protective. T ere is an inverse asso-
skill), and keeps arming. T ree years later, he returns with ciation between children living on arms and asthma incidence
a chronic cough, weight loss, dyspnea, atigue, and clubbing (another eather in the cap o Iowa). Presumably, this is related
o the ngers. to the greater variety o antigen exposure.
Ch Apt Er 3 • Pu l mo n o l o g y 99

Answer 3.3.2 The correct answer is “C.” Patients with asthma

CASE 3.3 will have a decreased FEV1. T e FVC may all as well, but FEV1
A 20-year-old woman with no signi cant past medical his- alls rst and to a greater degree as the lung becomes obstructed.
tory presents with a 2-month history o episodic shortness T e ratio o FEV1/FVC is very sensitive to air ow limitations, and
o breath. T ese symptoms began with an upper respiratory FEV1/FVC < 0.7 (not predicted, just the ratio o the two numbers)
tract in ection. She has ts o coughing and trouble catching is generally considered diagnostic o obstructive airway disease.
her breath with exertion. She states that her breath “sounds T e rest are incorrect. LC is not measured by spirometry (which
like whistles” at times. She tried a riend’s albuterol inhaler is why “E” is incorrect); but i it were, LC may be increased in
with some improvement and wonders i she has asthma. On patients with obstructive airway disease due to air trapping.
examination, she is breathing com ortably at 16 times per
minute and her oxygen saturation is 96% on room air. Her Your patient’s o ce spirometry shows the ollowing:
lungs are clear to auscultation, and the remainder o her Normal FVC.
examination is unremarkable. You want to better categorize FEV1 82% predicted.
this patient’s disease. FEV1/FVC 0.68.
Question 3.3.3 These ndings are most consistent with
Question 3.3.1 Which o the ollowing tests is most appro which o the ollowing?
priate to order now? A) Normal spirometry.
A) Spirometry. B) Obstructive lung disease.
B) Chest x-ray. C) End-stage emphysema.
C) Arterial blood gas (ABG). D) Interstitial brosis.
D) Methacholine challenge. E) Obesity-hypoventilation syndrome.
E) Chest C .
Answer 3.3.3 The correct answer is “B.” Always go rst to the
Answer 3.3.1 The correct answer is “A.” Since this patient has FEV1/FVC ratio. In this case, it is < 0.70, which is suggestive
symptoms o bronchospasm, spirometry will be essential in o airway obstruction. T e in ormation provided here lacks
determining i there is objective evidence o obstructive lung data regarding reversibility, so you could not really di erenti-
disease. However, spirometry results are o en normal in mild ate between chronic obstructive pulmonary disease (COPD)
cases o asthma, especially when the patient is asymptomatic. and asthma. But this is clearly not end-stage emphysema, so
Bronchoprovocation testing, with methacholine or histamine, “C” is incorrect. “D” is incorrect. Interstitial brosis is generally
may be use ul in such cases, but should ollow basic spirometry. marked by a restrictive pattern on spirometry and decreased
Although chest radiography (x-ray or C ) may reveal an unsus- LC. Both ow rate (e.g., FEV1) and FVC are decreased in inter-
pected process, it is not indicated in otherwise healthy patients stitial lung diseases but in proportion to each other. T us, the
with symptoms o bronchospasm. Bacterial pneumonia is a FEV1/FVC is o en normal or elevated. See able 3-1 or more
potential precipitant o bronchospasm that may be diagnosed on interpreting spirometry results.
on chest x-ray, but this patient has no constitutional symptoms
(like ever) associated with serious bacterial in ection. Obtain- Six months a er you discuss her ndings and prescribe
ing an ABG may be help ul when a patient presents with respi- inhaled beta-agonist therapy, she returns with complaints o
ratory distress but certainly not in the of ce setting. continued wheezing and di culty breathing. Her symptoms
are brought on by cold weather and exercise and she uses her
inhaler two times per week or less. She woke up two nights
over the last 6 months with shortness o breath and coughing.
a r b s p h sh -
Her albuterol still works or these symptoms, but she nds
rb h p s s s h s -
them bothersome and asks, “Why haven’t I gotten over this?”
s p r sp r r r .th rb
(P c o 2) sh b p h h p . Question 3.3.4 How would you categorize this patient’s
t h s, r pp r a Bg h r rb - respiratory state?
s r sp r r s A) Intermittent asthma.
r r sp r r r . B) Mild persistent asthma.
C) Moderate persistent asthma.
D) Severe persistent asthma.
Question 3.3.2 I this patient has mild asthma, which o
E) Recurrent lower respiratory tract in ections.
the ollowing pulmonary unction test results would you
expect to nd? Answer 3.3.4 The correct answer is “A.” According to the
A) Forced vital capacity (FVC) 50% o predicted. National Asthma Education and Prevention Program (2007
B) Forced expiratory volume in 1 second (FEV1) 100% o predicted. NHLBI/NAEPP guidelines; able 3-2), your patient meets the
C) FEV1/FVC ratio < 0.7. criteria or intermittent asthma. In such patients, mild symp-
D) otal lung capacity ( LC) 50% o predicted. toms correspond to an FEV1 (not an FEV1/FVC ratio) that is
E) FEV1/ LC < 0.7. greater than 80% predicted.
100 Fa mil y med ic in e exa min a t io n & Bo a Rd Review


PFT Result Obstructive Pattern Restrictive Pattern
Fev 1 < 80% pr d r s pr p r ss

Fvc d r s < 80% pr

Fev 1/Fvc < 0.7 > 0.7

FeF25–75% < 60% pr d r s pr p r ss

t lc n r r d r s

d lco n r r sh ; d r s r s r sr s s ;
r r r s c o Pd r r s r r s sk
r sr s s

Fev 1, r pr r 1s ; Fvc , r p ; FeF25–75, r pr r

25–75% p ;t l c , p ;d l co , s p h r rb ;
c o Pd , hr bs r p r s s .


Determine Severity When Initiating Therapy

Classification of Asthma Severity (≥12 years of age)
Components of Severity Persistent
Mild Moderate Severe
Symptoms ≤2 days/week >2 days/week but not daily Daily Throughout the day
Nighttime awakenings ≤2×/month 3–4×/month >1×/week but not nightly Often 7×/week
SABAa use for symptom >2 days/week but not daily
≤2 days/week Daily Several times per day
control (not prevention of EIBb) and more than 1× on any day
Interference with normal activity None Minor limitation Some limitation Extremely limited
• Normal EFV1
Lung function exacerbations
• EFV1 > 80% • EFV1 > 80% predicted • EFV1 > 60% but • EFV1 < 60% predicted
predicted <80% predicted
• EFV1/FVC normal • EFV1/FVC normal • EFV1/FVC reduced 5% • EFV1/FVC reduced > 5%

0–1/year ≥2/year
Exacerbations requiring
oral systemic corticosteroids Consider severity and interval since last exacerbation
Frequency and severity may fluctuate over time for patients in any severity category
Relative annual risk of exacerbations may be related to FEV1
Recommended step for Step 1 Step 2 Step 3 Step 4 or 5
initiating therapy and consider short course of
See bar chart in Figure 3–1 oral systemic corticosteroids
for treatment steps In 2–6 weeks, evaluate level of asthma control that is achieved and adjust therapy accordingly.
Sa Ba , sh r - h b -2 s ; b eiB, r s - br h sp s .
R pr r g s r h d ss m as h .n as h e Pr Pr r ,n i s s
H h. e p r P R p r 3, p s 305–310, 343–345. h p:// . h b . h. / s/ s h .
Ch Apt Er 3 • Pu l mo n o l o g y 101

Inte rmitte nt Persistent Asthma: Daily Medication

As thma Consult with asthma specialist if Step 4 care or higher is required. Consider consultation at Step 3.

Step 6
Step 5 Step up
Step 4 Preferred
if needed
Step 3 High-dose
Preferred High-dose (first, check
Step 2 Preferred Medium-dose ICS + LABA
Step 1 oral
Preferred Low-dose ICS + LABA environmental
AND corticosteroid
Preferred Low-dose ICS + LABA§ Alternative control, and
SABA* PRN ICS† OR Medium-dose AND comorbid
Alternative omalizumab for
Medium-dose ICS ICS + either Consider conditions)
Cromolyn, patients who
Alternative LTRA, omalizumab for Assess
LTRA,‡ have allergies
Low-dose ICS + theophylline, patients who control
nedocromil, or either LTRA, or zileuton have allergies Step down
theophylline theophylline, or if possible
zileuton (and asthma is
Patient Education, Environmental Control, and Management of Comorbidities at Each Step well controlled
Cons ide r s ubcuta ne ous a lle rge n immunothe ra py for pa tie nts who have a lle rgic a s thma a t S te ps 2 through 4 at least
3 months)
Quick-Relief Medication for All Patients
• SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at
20-minute intervals as needed. Short course of oral systemic corticosteroids may be needed
• Use of SABA >2 days a week for symptom relief (not prevention of EIBµ) generally Indicates inadequate control and
the need to step up treatment
† ‡ ‡ µ
* Short-acting inhaled beta2-agonist. Inhaled corticosteroid. Leukotriene receptor antagonist. Long-acting inhaled beta2-agonist. Exercise-incluced bronchospasm.

FIGURE 3-1. t k s p s r ppr h sh .

Question 3.3.5 Which o the ollowing is most appropriate Answer 3.3.6 The correct answer is “A.” Your patient now has
or this patient given that she has intermittent asthma? mild persistent asthma and should be started on an inhaled
A) Add theophylline. steroid. When asthma symptoms become more persistent (i.e.,
B) Add montelukast. when they occur > 2 days per week or the patient awakens rom
C) Continue albuterol as needed. sleep > 2 times per month), the in ammatory component o the
D) Schedule albuterol every 4 hours. disease should be addressed while simultaneously treating the
E) Prednisone 5 mg daily. bronchospastic component with short-acting beta-2 agonists.
Anti-in ammatory drugs are the mainstay o chronic asthma
Answer 3.3.5 The correct answer is “C.” As already discussed, therapy, and inhaled corticosteroids are the most ef cacious
this patient appears to have intermittent asthma. She is in with the ewest side e ects. Although ipratropium, cromolyn
no respiratory distress, is oxygenating normally, and is still sodium, and montelukast have a place in asthma treatment,
responding well to albuterol by her report. Although there is none o these medications is a rst-line agent. Ipratropium works
some debate about the role o inhaled steroids in intermittent through its bronchodilatory e ects, while cromolyn sodium is
asthma, the NAEPP and most experts do not recommend their a mast cell stabilizer. Montelukast is a leukotriene inhibitor. T e
use. Oral prednisone is certainly not indicated in this case. She long-acting inhaled beta-2 agonists, such as salmeterol, are only
should be continued on a short-acting inhaled beta-2 agonist, recommended at Steps 3 and higher o persistent asthma con-
such as albuterol, without the addition o another medication. trol ( able 3-2, Fig. 3-1; NHLBI recommendations, 2007).
“D” is incorrect. Scheduled albuterol actually yields less e ective
symptom control than does PRN use.
Your patient goes on to develop more requent recurrent symp- R b r h “r s”: p h h s>2
toms, such that she is using her albuterol inhaler more than three sh rb sp r kr q r r s -
times per week, although her nighttime symptoms are rare. r h k s h r s p s> 2 s
p r h sh b - r r , pr -
Question 3.3.6 Which medication is the most appropriate r b h r s r . as h ss
next step in treating this patient’s asthma? r h s r s p —
A) Inhaled triamcinolone. 74 p s h( hss h s r rs !). y
B) Inhaled salmeterol. r h s, h ps://
C) Inhaled cromolyn sodium. . h b . h. /h h-p r / s/ rr /
D) Inhaled ipratropium. sh - s/s r -r p r -2007
E) Oral montelukast.
102 Fa mil y med ic in e exa min a t io n & Bo a Rd Review

A) Inhaled triamcinolone and inhaled albuterol as a “rescue.”

B) Inhaled triamcinolone, oral montelukast, and inhaled
th k r h b rs ( . ., k s, z r -
albuterol as a “rescue.”
k s) r h z h s r
C) Oral montelukast and inhaled albuterol as a “rescue.”
h r p .i , h r r s s -
D) Inhaled albuterol as a “rescue.”
h s r s. t h sh b s p
E) Inhaled salmeterol and inhaled triamcinolone.
h s h s r s sh b h
r ; h r s bs r h s r s.
Answer 3.3.8 The correct answer is “B.” Leukotriene inhibitors
(e.g., montelukast, za rlukast) have demonstrated e ectiveness
Your patient does quite well over the next year, having very ew in reducing symptoms and improving peak ow in patients with
exacerbations. During one o her visits, you note slightly edem- aspirin sensitive asthma. Leukotriene inhibitors should be
atous nasal mucosa and nasal polyps. You prescribe intranasal used only in asthma patients who are already using a corticoste-
steroids. roid inhaler—or those who cannot tolerate inhaled corticoste-
roid therapy. T ere ore, “C” is not an appropriate choice. “D” is
One night when you are on call, she comes in severely dys- incorrect because there is no anti-in ammatory. Although “E”
pneic with audible wheezing. She talks in two- or three-word o ers an anti-in ammatory agent, there is no rescue inhaler,
phrases. She reports a headache today, which she treated with and patients with asthma must always have access to a short-
aspirin (something she never takes but a riend gave it to her acting inhaled bronchodilator.
thinking it was acetaminophen). Her asthma attack started
about an hour a er the aspirin dose. She has been otherwise
well. She denies ever, rhinorrhea, nasal congestion, and sore
o h r n Sa id s h b p “ sp r - r-
throat. Her respiratory rate is 40, heart rate 120 bpm, and
b ” s h .th h r s h h r s b
oxygen saturation 88% on room air. She has poor air move-
b pr - - r rs h s
ment on auscultation o her lung elds.
rb b c o x-1 h b .

Question 3.3.7 Which o the ollowing is the most likely

reason or this patient’s acute exacerbation o asthma? Question 3.3.9 Which o the ollowing medications, when
A) Viral upper respiratory in ection (URI). used alone as maintenance therapy in persistent asthma,
B) Sinusitis. is associated with an increased risk o asthma related
C) Noncompliance with inhaled albuterol. mortality?
D) Sensitivity to aspirin. A) Inhaled uticasone.
E) Noncompliance with nasal steroids. B) Inhaled salmeterol.
C) Oral za rlukast.
Answer 3.3.7 The correct answer is “D.” It is likely that this D) Oral prednisone.
patient has aspirin sensitivity. Up to 10% o adults with asthma
have the clinical triad o asthma, aspirin sensitivity, and nasal Answer 3.3.9 The correct answer is “B.” Inhaled salmeterol,
polyposis. Patients with asthma should be warned about the when used alone as a controller agent or asthma, has been asso-
potential or exacerbations resulting rom consumption o aspi- ciated with a two- to our- old increase in the risk o death related
rin and nonsteroidal anti-in ammatory drugs (NSAIDs). T e to asthma or other respiratory conditions. T us, the Food and
drug-induced bronchial constriction caused by these medica- Drug Administration (FDA) has mandated a “black box” warn-
tions can have an abrupt onset with severe symptoms. Patients ing be applied to salmeterol-containing products. It is not known
with aspirin sensitivity can be desensitized with daily admin- whether inhaled steroid therapy is protective, but NHLBI/
istration o small amounts o aspirin, but this should be done NAEPP guidelines recommend adding long-acting inhaled beta-
care ully with close supervision. Although viral URIs requently agonists only a er inhaled steroids are already in use.
cause exacerbations o asthma, your patient did not report ante-
cedent symptoms o such an in ection. Further discussion o HELPFUL TIP:
the treatment o an acute asthma exacerbation can be ound in th p r p sh -
Chapter 1, “Emergency Medicine.” b rs . P s s h sh
sh r r p , h
A er a brie hospitalization, your patient recovers nicely. r s b -2 s s h s r r
Prior to this incident involving aspirin, she had been ree o s r . wh h r s pr b h p k
exacerbations or about a month. r , hs s r p s r
h r ss. a h p k
Question 3.3.8 In addition to a short course o oral ste r b s s p r h
roids, which o the ollowing medication regimens do you pr ss h b h
prescribe or this patient with aspirin sensitive asthma at h h r pr r h p .
Ch Apt Er 3 • Pu l mo n o l o g y 103

Me as ure Ac tual % Pre dic te d How do you interpret these ndings?

FVC 3.66 L 103 A) Chronic obstructive lung disease.
10 B) Restrictive lung disease.
FEV1 2.30 L 83
8 C) Fixed upper airway obstruction.
FEV1 /FVC 0.63 D) Poor patient e ort.
FEF(25–75) 2.15 L 51 E) Within normal range.
2 The correct answer is “C.” T e attened ow/volume loop is
0 consistent with a xed upper airway obstruction. In this case,
1 2 3 4 5 6
FEV1 and the FEV1/FVC ratio may look like other obstruc-
tive diseases (i.e., asthma, COPD), so you have to look at the
ow/volume loop (always a good idea). Some examples o
–6 ow/volume loops are given below (Fig. 3-3).
–10 CASE 3.4
Volume (L)
You are seeing a 65-year-old male in the emergency depart-
ment (ED) where he presented with complaint o increasing
FIGURE 3-2. Sp r r r s s. shortness o breath. He has obvious di culty breathing and
cannot speak in ull sentences. However, you are able to elicit
that he has been having increasing respiratory problems over
Objectives: Did you learn to . . . the last 3 to 4 days. He has known COPD with FEV1 o “less
• i r rs br h sp s ? than one” (normal FEV1 is about 4 L or a 50-year-old male
• e s p s h z sp ? and 3 L or a 50-year-old emale— or the calculations based
• c ss sh ? on age, etc., see www.hankconsulting.com/Re Cal.html). He
• Pr s r b ppr pr s r r has been using his inhalers much more than usual but with
p rs s sh ? minimal improvement. He has smoked one pack per day
• d s rb h r s h , sp r s s , s since age 18 (but proudly points out he quit 2 days ago) and
p p s s? has a past medical history o high cholesterol, obesity, and
On examination, he has a respiratory rate o 26 to 28,
QUICK QUIZ: SPiRo met Ry heart rate o 100 bpm, blood pressure o 130/90 mm Hg,
and temperature o 37.7°C. His O2 saturation is 84% on
A 60-year-old emale who smokes two packs o cigarettes per room air. On auscultation, you do not appreciate much
day complains o shortness o breath and ullness in her throat. due to his body habitus but you still manage to hear some
You obtain spirometry in the of ce and the results are given wheezing. He has a normal cardiac examination and no
above along with the ow/volume loop (Fig. 3-2). lower extremity edema.

Flow Flow
Flow 8 8
6 6
4 4
2 2
0 0

–2 –2 –2

–4 –4 –4

–6 –6 –6
–1 0 1 2 3 4 –1 0 1 2 3 4 –1 0 1 2 3 4
Volume Volume Volume
Norma l pa tte rn Obs tructive pa tte rn Re s trictive pa tte rn
FIGURE 3-3. Sp r r r s s.
104 Fa mil y med ic in e exa min a t io n & Bo a Rd Review

Question 3.4.1 What is the next best step to help this patient? now you cannot tell easily whether his O2 needs are going up
A) Per orm emergent endotracheal intubation. or down. “D” is o special note. Patients with COPD who look
B) Administer supplemental O2 via nasal cannula. com ortable may be becoming hypercapnic and developing CO2
C) Administer Solu-Medrol, 1 g IV. narcosis. T us, while com ort is a goal, it may not be the best
D) Start antibiotics IV. judge o clinical status in patients with COPD exacerbations. o
E) Obtain a chest x-ray. assess CO2 levels, you will need an ABG or VBG.

Answer 3.4.1 The correct answer is “B.” T is patient is hypoxic, Your patient is now on 5 liters per minute (LPM) o oxygen via
and your rst priority should be to improve his oxygenation. nasal cannula. You obtain an ABG: pH 7.29, PCO2 74 mm Hg,
T ere exists a theory that oxygenating patients with COPD will PO2 58 mm Hg. T e patient is awake and alert but says that he
suppress their respiratory drive. T e classical teaching (mostly still eels “like dirt.” He remains tachypneic, in obvious respi-
incorrect) is that COPD causes a switch rom carbon dioxide ratory distress, with a respiratory rate o 28. Albuterol and
levels driving respiration to oxygen levels driving respiration. ipratropium are given via nebulizer.
While this may be partly true, urther study has suggested that
the main reason COPD patients are at risk o worsening hyper- Question 3.4.3 What is the best next step?
capnia is due to loss o hypoxic pulmonary vasoconstriction A) Clearly, he is ailing therapy—emergently intubate.
and worsening ventilation–per usion mismatch that occurs B) Increase his O2 to 100% via ace mask.
with excess oxygen delivery. Regardless o that, you need to rst C) Initiate noninvasive positive pressure ventilation
worry about this patient’s oxygenation. (e.g., BiPAP).
“A” is incorrect. T e patient is protecting his airway and you D) Start IV antibiotics.
have not attempted improving his oxygenation with less inva- E) Obtain a chest C with PE protocol (you are barking up the
sive methods yet. Administering steroids, IV or PO, will have wrong bronchial tree).
no immediate e ect on his respiratory status. In act, IV steroids
might be worse than PO steroids (there is question o whether Answer 3.4.3 The correct answer is “C.” T is patient is retain-
higher IV doses cause immunosuppression and subclinical ing CO2 despite tachypnea and is in impending respiratory
myopathy; see Am J Respir Crit Care Med. 2014;189:1052). Anti- ailure. He is also not oxygenating well despite low- ow oxy-
biotics and a chest x-ray may be reasonable, but with low O2 gen. Noninvasive positive pressure support (BIPAP) can relieve
saturations, your priority is to quickly improve your patient’s hypercapnia and improve oxygenation by decreasing work o
oxygen status. breathing without requiring intubation and its associated mor-
bidity. O en IV antibiotics (“D”) are used or empiric therapy in
severe exacerbations o COPD, but again, improving the respi-
ratory status comes rst. He is hypoxic, but his main problem
P s h sp r c o Pd rb
is CO2 retention—increasing his O2 delivery will not alleviate
(h r rz b r s sp , sp pr -
that (thus, “B” is incorrect). Although his respiratory status is
sp p r ) sh b r h r-
tenuous, he is not in imminent respiratory ailure, and intu-
s r s ( r pr s s q iv s r s),
bation (“A”) is not warranted at this time. Chest C (“E”) can
b h rs r sp r r r p h s
rule out a PE in this hypoxic patient and may con rm COPD
( r s b s r p b , z hr -
changes including emphysema but will greatly delay treatment
, , , h rs) -
and would not change your immediate course o action.
h br h rs. S pp r h r p h s pp -
s r q r s .
A er several hours o noninvasive positive pressure ventila-
tion, your patient is doing well and he is trans erred out o
Question 3.4.2 When initiating supplemental oxygen by the intensive care unit (ICU). When you see him the next day,
nasal cannula, you instruct the nurse to keep the patient’s his medications include inhaled bronchodilators, ce riax-
oxygen saturation: one, azithromycin, and prednisone. A chest x-ray shows no
A) Between 96% and 100%. evidence o in ltrate. He is weaned rom the positive pres-
B) Between 90% and 95%. sure support and is now on 2 LPM o oxygen by nasal can-
C) Between 85% and 89%. nula. He appears com ortable, with a respiratory rate o 14
D) At whatever saturation he looks most com ortable. and an oxygen saturation o 95%.

Answer 3.4.2 The correct answer is “B.” T e primary goal o Question 3.4.4 Now you know that he has COPD, what
supplemental oxygen is to reduce the risk o tissue hypoxia. would be the best treatment or him?
Maintaining oxygen saturations above 90% (or PaO2 60–65 mm) A) Inhaled long-acting beta-agonist (LABA) + albuterol.
will ensure tissue oxygenation. Higher oxygen saturations may B) Inhaled steroid + albuterol.
result in CO2 retention and hypercapnia, as noted earlier. Also, C) Inhaled steroid + LABA + albuterol as needed.
aiming at 100% with excessive levels o O2 supplementation D) Albuterol.
takes away an important patient assessment parameter because E) Albuterol and theophylline.
Ch Apt Er 3 • Pu l mo n o l o g y 105

Answer 3.4.4 The correct answer is “C.”T is is a bit tricky, but due Answer 3.4.5 The correct answer is “E.” Aside rom oxygen, no
to the severity o his exacerbation, “C” is the best choice. Compared medical therapy has clearly demonstrated a mortality bene t or
with patients with asthma, where long acting bronchodilators are stable COPD (see Fig. 3-4 or stage o COPD and appropriate
not indicated as rst-line therapy, COPD patients have a clear symp- treatment). Another therapy to consider in advanced COPD is
tomatic bene t rom long-acting bronchodilators. T e two available pulmonary rehabilitation (PR). While having no de nite e ect
choices are anticholinergics (e.g., tiotropium) or LABAs (e.g., sal- on survival, PR improves dyspnea and quality o li e scores
meterol or ormoterol). Either choice is ne. An inhaled steroid while reducing the number o hospitalizations and days in hos-
does not modi y the long-term decline in FEV1 in patients with pital. Finally, there is a new oral phosphodiesterase inhibitor,
COPD. However, it will reduce the requency o exacerbations ro umilast (Dalisrep), or severe COPD. As you probably
and thus improve health status. Current guidelines recommend already know, your authors are curmudgeons who don’t like
addition o inhaled steroids with FEV1< 50% predicted and re- anything new. But ro umilast is particularly on our bad list. It
quent exacerbations (e.g., three in the last 3 years), see Figure 3-4. increases FEV1 by 45 mL over placebo. It has no e ect on qual-
ity o li e and exacerbations are 1.3/year with placebo and 1.2/
year with rol umilast. It also causes diarrhea and depression/
a r th r S (a t S) s rz
suicidality. Nonetheless, you should know about it.
bs r r s s b s h p r pr -
Fev 1
Note: Long-acting bronchodilators can be either a beta agonist
h p . t h r sp s br h -
r s s rz b a t S. t s h h r s
or an anticholinergic.
s r sp s br h r, h r h s b
r s b h 200 r s s HELPFUL TIP:
12% h Fev 1. n h h s r s sh b s h s h
S 3 S 4( r s r ) c o Pd b s
h g b r o bs r l ds s
Holding his inhalers and smiling toothlessly, your patient (g o l d ) s. t h r s b p s h
asks, “Which o these is going to keep me alive—just in case I S 1 rS 2( ) c o Pd h r s s
can’t a ord both?” ( r s p ).

Question 3.4.5 Which o the ollowing medication regimens

has demonstrated decreased mortality in the treatment o Later that year, the same patient gets admitted to the hospital
stable COPD? or community-acquired pneumonia. During his stay in the
A) Inhaled tiotropium (a long-acting anticholinergic). hospital, the hospitalist orders a C chest “to rule out other
B) Inhaled salmeterol (LABA). things.” T e patient recovers rom his in ection and returns to
C) Inhaled ipratropium (a short-acting anticholinergic). you with the CD o his C chest images. T e reading o the C
D) Inhaled corticosteroid. chest describes a 2-cm pulmonary nodule in the right upper
E) None o the above. lobe along with extensive subcarinal lymphadenopathy.

S ta ge 1 S ta ge 2 S ta ge 3 S ta ge 4
FEV1/FVC<70% FEV1/ FEV1/ FEV1/FVC <70%
FEV1>80% FVC <70% FVC <70% FEV1 <30% or
pre dicte d FEV1 <80% FEV1 <50% <50% with
but >50% but >30% chronic re s p
fa ilure

Mild COP D Mode ra te S e ve re COP D Ve ry S e ve re


Influe nza va ccine , s moking ce s s a tion, s hort a cting bronchodila tor

Long a cting bronchodila tor, P ulmona ry re ha bilita tion

Inha le d Glucocorticoids if fre que nt

e xa ce rba tions
Long te rm
Oxyge n, S urge ry

FIGURE 3-4. g b bs r s s c o Pd s r h r p .
106 Fa mil y med ic in e exa min a t io n & Bo a Rd Review

Question 3.4.6 What is the next best step in management spontaneously combusting right and le (like Spinal ap
o this patient? drummers).
A) Repeat C chest in 3 months. D) Low- ow O2 used at least 15 hours a day signi cantly enhances
B) Repeat C chest in 6 months. survival.
C) Re er or bronchoscopy with endobronchial ultrasound- E) Low- ow O2 is a well-tolerated and e ective treatment or
guided biopsy. obstructive sleep apnea.
D) Re er to an oncologist.
E) Re er or a mediastinoscopy. Answer 3.4.8 The correct answer is “D.” Patients who use low-
ow O2 at home or 24 hours a day have an improved rate o sur-
Answer 3.4.6 The correct answer is “C.” T is patient probably vival. Patients should be encouraged to use O2 at least 15 hours
has a malignant disease and tissue is needed to either diagnose a day i possible. “B” is incorrect because patients need at least
it or rule it out. Bronchoscopy with endobronchial ultrasound 15 hours o O2 per day to have any signi cant bene t with regard
(EBUS)-guided ne-needle biopsies is a minimally invasive pro- to pulmonary hypertension. “C” is incorrect. Clearly, smoking
cedure that can relatively sa ely obtain a tissue sample or the while on O2 is not a good idea, but patients can turn o their O2
pathologist. T ere is good evidence that EBUS has high sensitiv- supply while smoking.
ity and speci city compared with PE scanning. “A” and “B” are
incorrect as this patient has a nodule that is larger than 1 cm along
with mediastinal lymphadenopathy. T is needs to be worked up HELPFUL (AND IMPORTANT) TIP:
and cannot wait 3 to 6 months. “D” is incorrect. Your patient will d s ss h p 20% p s h sp z
likely need to see an oncologist, but you need to rst provide a h c o Pd rb k r -
tissue diagnosis. “E,” mediastinoscopy, would likely provide you h Pe. d ’ rr r r s !
with the diagnosis, but it is a ar more invasive procedure than
bronchoscopy and carries higher mortality and morbidity.
Objectives: Did you learn to . . .
• R z p pr s hs s s p s
i r s h p alf p s treated r c o Pd • d s rb s s r r r c o Pd ?
’ h .S b r . c h k PFt s (c h s .
• d p p h p h p r p ?
• m s r rb s c o Pd ?
• dr h r p r hr c o Pd ?
Your patient returns with increasing dyspnea now at rest. His • i s s sp h r h c o Pd pr s
p hk c o Pd ?
biopsy was negative. Despite both o you being blue in the
ace, he has not quit smoking.
Question 3.4.7 Criteria or the use o continuous low ow oxy
gen in those with COPD include all o the ollowing EXCEPT:
A) PO2 < 55 mm Hg. In a patient with COPD, a lung transplantation re erral can be
B) Oxygen saturation < 88%. considered:
C) PO2 o < 59 mm Hg with evidence o cor pulmonale. A) Once the patient requires oxygen.
D) Episodic sleep apnea-related desaturations at night. B) When you eel you have run out o interventions.
C) Once insurance accepts your re erral.
Answer 3.4.7 The correct answer is “D.” Episodic sleep apnea– D) A er the patient meets strict criteria or the re erral.
related oxygen desaturations, while a cause or concern and ame- E) I the patient’s amily keeps asking or the re erral.
nable to treatment (e.g., CPAP), is not one o the criteria or the
use o continuous low- ow oxygen. T e other choices are cor- The correct answer is “D.” T e International Society or Heart
rect. “C” deserves some special attention. Evidence o cor pul- and Lung ransplantation created a set o criteria or when to
monale can include “p-pulmonale” on ECG, peripheral edema, consider transplantation and, more importantly, when should
or a hematocrit > 55%. you consider re erral or a lung transplant consultation. In COPD
patients, the indication or re erral is easy to remember and con-
Question 3.4.8 Concerning hypoxemic patients with COPD, sists o BODE index > 5 (BODE stands or Body-mass-index,
which o the ollowing is true? air ow Obstruction, Dyspnea, and Exercise, which are the char-
A) Patients on continuous, low- ow O2 become oxygen depen- acteristics used in the index). T e BODE index is an alternative
dent and cannot unction without it. to the GOLD criteria. T e BODE index incorporates unctional
B) Continuous low- ow O2 used or at least 8 hours a day helps criteria such as breathlessness and 6-minute walking distance.
to reverse pulmonary hypertension. Find a BODE calculator here: http://www.qxmd.com/calculate-
C) Concurrent smoking is a contraindication to the prescrib- online/respirology/bode-index. Criteria or transplantation in
ing continuous low- ow home O2 because patients are COPD are more complex and are beyond the scope o this book.
Ch Apt Er 3 • Pu l mo n o l o g y 107

ound in patients with a PE is sinus tachycardia. But alas, Sarah

CASE 3.5 had a normal heart rate. T e other choices can certainly be ound
Ms. Sarah Bellum (i you’re not smiling, try saying the name with this condition but are ar less requent. O note, the “text-
out loud or the joke is just lame . . .) is a 32-year-old Caucasian book” S1Q3 3 ECG rarely occurs and historically traces back to
emale who presents to your ED with shortness o breath. She a hand ul o patients in the 1930s that had massive pulmonary
just returned home a er the International Con erence on emboli. Even i you do spot this pattern on an ECG, it is not
Coordination in London. Immediately a er walking through speci c enough to con rm the diagnosis. In the end, the clini-
her ront door, she became acutely short o breath (not attrib- cal signs attributed to pulmonary emboli (such as the shortness
utable to the Justin Bieber poster in her living room). T is o breath and chest pain) are requently more valuable than any
is associated with some moderately sharp chest pain located abnormal ECG nding.
along the le side o her chest. T e pain seems worse when
she attempts to breathe deeply. As you attempt to rule out other potential etiologies or the
patient’s symptoms (e.g., pneumonia, atelectasis, and pneu-
Question 3.5.1 Which important question(s) do you next mothorax), you order a trusty chest radiograph.
ask Ms. Bellum?
A) Do you smoke cigarettes? Question 3.5.3 What is the most common radiographic nd
B) When was your last menstrual period? ing in a patient with a PE?
C) Have you had surgery recently? A) Pleural e usion.
D) Do you have a history o kidney disease? B) No acute cardiopulmonary processes.
E) All o the above. C) Westermark sign.
D) Hilar/mediastinal enlargement.
Answer 3.5.1 The correct answer is “E.” Each o these questions E) Hampton hump.
addresses risk actors associated with pulmonary embolism (PE)
and/or deep vein thrombosis (DV ). Smoking cigarettes and Answer 3.5.3 The correct answer is “B.” Admittedly, this one is
recent surgery are strong risk actors, as is an active pregnancy. a bit tricky. Approximately 75% o the chest radiographs in the
Addressing a patient’s menstrual cycle serves as a natural segue setting o PE are abnormal. However, there are numerous causes
to a discussion about the use o oral contraceptives, which, too, is or these abnormalities and none o them individually surpass
a prominent risk actor. As or renal disease, nephrotic syndrome the requency o the normal chest radiographs. Speci cally, the
has been associated with an increased risk o PE. “textbook” ndings o Westermark sign (loss o peripheral vas-
cular markings) and Hampton hump (a wedge-shaped opacity
A er urther verbal probing, you discover that Ms. Bel- due to pulmonary in arction) are in requent, and both have a
lum recently completed her menstrual cycle and the other low sensitivity and low speci city. In short, all the other options
presented questions turned up no risk actors. However, can be seen as the result o a PE but none are more requent than
your smooth segue did reveal that she takes low-dose estro- a normal chest radiograph.
gen or birth control. During this discourse, you also learn
that her aunt had a blood clot in her leg once. She has no ECG and chest radiograph in hand, you turn your attention
urther details but does not think that her aunt had any toward ordering the appropriate laboratory tests to solidi y
urther complications rom this condition. Regardless, PE your presumptive diagnosis. You are working with a medical
just took a violent leap to the top o your di erential. You student who suggests a number o lab tests. You agree with
glance at her vitals (temperature 37.1°C, heart rate 92 bpm, most o them, but shoot him down on one.
blood pressure 129/68 mm Hg, respiratory rate 21, SpO2 95%
on room air) and notice that she appears mildly uncom ort- Question 3.5.4 Which test should you AVOID ordering?
able but not in any acute distress. Her physical examination A) CBC.
is entirely unremarkable. You order an ECG on the patient B) D-dimer.
to evaluate or potential cardiac etiologies or her symptoms. C) P /P .
D) Basic metabolic panel (Na+ , K+ , Cl− , CO2− , BUN, Cr − , and
Question 3.5.2 Assuming Ms. Bellum does have a PE, what glucose).
is her ECG most likely to show? E) Urine pregnancy test.
A) S1Q3 3.
B) Nonspeci c S - wave changes. Answer 3.5.4 The correct answer is “B.” T e D-dimer can be a
C) Sinus tachycardia. blessing or some but is the bane o existence or others. In this
D) Normal sinus rhythm. patient, a D-dimer is not use ul. T is test has great sensitivity
E) Multi ocal atrial tachycardia. but poor speci city. It is positive in ar more conditions than
PE. Used as a “rule-out” test or PE, it only applies in low-risk
Answer 3.5.2 The correct answer is “D.” T e most common patients. Ms. Bellum is not a low-risk patient as suggested by the
ECG nding associated with the diagnosis o PE remains nor- pulmonary embolism rule-out criteria (PERC) rules (see Help-
mal sinus rhythm. With that said, the most common arrhythmia ul ip) due to her use o exogenous estrogen. T e Wells criteria
108 Fa mil y med ic in e exa min a t io n & Bo a Rd Review

or PE place her in the moderate-risk group (16.2% risk o PE). TABLE 3-3 WELL’S SCOr E FOr pEa
As such, even a negative D-dimer is insuf cient or ruling out
c s sp d vt 3p s
the diagnosis. As or the other tests, they all serve a valuable
role in her evaluation. For instance, the CBC could provide evi- n r ss r k h Pe 3p s
dence o anemia, while the P /P may reveal a coagulopathy.
t h r > 100 1.5 p s
Assessing her renal unction may be needed or her evaluation
moving orward, and the same can be said or veri ying her i b z r≥3 s rs r r h 1.5 p s
nongestational status. Plus, a urine pregnancy test is per ormed pr s4 ks
on almost every woman in an ED. It might as well be part o the
Hs r d vt r Pe 1.5 p s
triage process.
m h 6 hs 1p
T at pesky med student seemed to know a lot about the PERC Pr s h p ss 1p
rules and Wells criteria. But when he listed the Wells criteria,
he got one wrong. S r >6: h h pr b b Pe (78%)
S r 2–6: r pr b b Pe (27.8%)
Question 3.5.5 The Wells criteria or PE include all o the S r <2: pr b b Pe (<3.4%).
- r s only s r h pr b b p .o h r s ,
ollowing EXCEPT: h p s - s pr b b h r - r s h h
A) Estrogen use. h r sk r Pe.
B) Pulse > 100.
C) Previous history o venous thromboembolism.
D) Clinical symptoms and signs consistent with PE.
E) Hemoptysis. T e CBC, coagulation studies, and basic metabolic panel all
return within normal limits. In addition, Ms. Bellum is not
Answer 3.5.5 The correct answer is “A.” While an important pregnant. T us, you wish to ( nally) solidi y that diagnosis
risk actor or PE, estrogen use is not included in the Wells crite- you have suspected or quite some time.
ria. All the others count in the Wells criteria ( able 3-3). Using a
medical calculator website, such as www.medcalc.com, is most Question 3.5.6 Since you do not put her in the low risk cat
help ul. egory by your clinical judgment, what diagnostic study
should you order?
A) VQ (ventilation–per usion) scan.
B) C scan o the chest without contrast.
C) C scan o the chest with contrast.
t h PeRc r s r s r s h -
D) Pulmonary angiogram.
rz p -r sk r p r
E) Compressive Dopplers o the lower extremities.
Pe .i h p s all h , Pe s
r ( ss b h p s r sk):
Answer 3.5.6 The correct answer is “C.” T e American College
1) a < 50.
o Radiology (ACR) lists the C scan o the chest with contrast
2) H r r < 100.
(i.e., C angiography or C A) as the modality o choice in
3) S o 2 > 94%.
stable patients with a suspected PE. T e C A is considered
4) n r s .
to be the standard o care. Its bene ts include the act that it
5) n h p s s.
is noninvasive, cheaper than pulmonary angiography, and ar
6) n r hs r r rs r r .
more available than VQ scans. It should be noted that pulmo-
7) n pr r d vt r Pe.
nary angiography still remains the “gold standard” or diag-
8) n h r s .
nosing pulmonary emboli, but that is more o an academic
point. As or VQ scans, they are not available in many locales
and o en return nondiagnostic. However, they can be used in
HELPFUL TIP: a patient with a normal chest x-ray. A chest C without con-
R b r d- r -r sk p s. t h s trast (“B”) will not enhance the pulmonary arteries, making
s p r s s h ct r p s r s- the diagnosis o a PE ar more dif cult, i not impossible. Since
s r r . th r r 20- r- most pulmonary emboli are believed to arise rom the lower
r 64-s h s c t s 1:142 (r ) extremity venous system, “E,” Dopplers o the legs, could be
(Ja ma . 2007;298:317–323)! S s l . 2009;374: considered i the patient was a poor candidate or both C A
1160 JP r. 2009;154:912 h rs. P s, and VQ scan (e.g., COPD and Stage 4 chronic kidney disease).
25% “p s ”c t s -r sk p s r s p s- But this approach is obviously not diagnostic o PE; it would
, h h h (Am just help you determine i the patient has an active thrombo-
J Roentgenol. 2015;205:271). sis, and you would manage the same whether she has a PE or
DV or both.
Ch Apt Er 3 • Pu l mo n o l o g y 109

the American College o Chest Physicians (ACCP), published

online in January 2016, recommends novel oral anticoagulants
S pr rs s Pe b s ct a
(e.g., dabigatran, apixaban, and others) over war arin or treat-
h b d pp rs h s. w h b h? i
ment o PE in patients without cancer; however, the ACCP
d vt Pe, r h s s
grades this recommendation as “weak with moderate quality
r h h r. a r h s
evidence.” Continue to look at the whole patient when making
Pe, b h .S h d vt .
anticoagulation decisions.

Question 3.5.8 How long are you going to maintain this
i pr , b h h s ct v/Q s r -
patient on anticoagulation?
p b p s p b r -
A) 3 months.
s (o bs g . 2011;118:718).
B) 6 months.
C) 9 months.
D) Li etime.
As keenly suspected, Ms. Bellum’s C A o the chest reveals a
Answer 3.5.8 The correct answer is “A.” For a PE that has a
moderate-sized pulmonary embolus in the le pulmonary
reversible cause (oral contraceptive pills in this patient with a
artery. Her vital signs are still stable and her pain is well-
long airplane trip), 3 months o anticoagulation is adequate. For
controlled with intravenous morphine. She is surprised by the
those with a second PE, li etime anticoagulation is warranted.
diagnosis you give her but appears to be taking it in stride.
For those with a cryptogenic PE or PE rom an acquired or
Question 3.5.7 What is the optimal management plan or inherited thrombophilia (e.g., Factor V Leiden), recommenda-
the patient moving orward? tions are all over the place rom 3 months to li e. Nine months
A) Bolus her with un ractionated heparin (UFH), start her on is likely adequate or a patient with a PE rom an irreversible
oral war arin, and discharge her to home. cause, although patients go back to their pre-treatment risk as
B) Administer a dose o enoxaparin in the ED, provide educa- soon as you stop anticoagulation. And, a rst PE trumps every-
tion, and discharge the patient to home with primary care thing else in terms or risk actors or a second PE—including
ollow-up in the next 2 to 3 days. all those ancy thrombophilia tests! So, nding that thrombo-
C) Start the patient on low–molecular-weight heparin (LMWH), philia does not necessarily help your decision-making process.
initiate oral war arin therapy, and admit the patient to the Note that some guidelines suggest anticoagulation or li e a er
amily medicine service. a rst cryptogenic/unprovoked PE i bene t seems to outweigh
D) Bolus her with UFH, initiate a UFH drip, and admit the risks. T is should be decided a er 3 months o anticoagulation.
patient to the amily medicine service. (Chest. 2012;141(2)(Suppl):7S–47S.)
E) Start her on oral war arin and discharge her to home with
primary care ollow-up in the next 2 to 3 days.
Answer 3.5.7 The correct answer is “C.” Full anticoagulation a a– r s ss /
is considered mandatory or all patients with a PE. While dis- p r s s h rs b r -
charging a patient with only a DV is considered standard o s, s s, r h - - sh ,
care, this is not (yet) true or PE. T us, any plan that centers r sp r r s r ss s r (a Rd S), r b s ,r -
on a discharge to home is incorrect (a 2014 Cochrane Data- s s r s h , c o Pd h r ,
base review concluded that the available evidence is insuf cient br h ss h p r s h . t h s,
to recommend outpatient therapy and that more studies are a– r s sp r Pe. l k s ,
needed). With regard to selecting an anticoagulant, current r a– r r s r
evidence does not support the use o one agent over another; r Pe! i , p s h r
UFH, LMWH, and ondaparinux are all appropriate. Regard- s s , h Pio Ped s r
less o the selected anticoagulant, the current recommenda- h s r a– r p s
tions stipulate the initiation o war arin at the time o diagnosis h h Pe.
as well. T e UFH, LMWH, or ondaparinux should be contin-
ued until the patient’s INR has been therapeutic (2–3) or at
least 24 hours and at least 5 days. Note that apixaban, dabi- HELPFUL TIP:
gatran, and rivaroxaban can all be used to treat and prevent o 88% p s h Pe r h p , 70% h
PE. Like war arin, dabigatran requires 5 days o overlap with sp r h p , 65% h p r p , s
LMWH when used as treatment. Avoid edoxaban (Savaysa) i s 30% r h r .th p h r s h
possible. It can only be used in those with a CrCl o less than h h s sp h r h s sp
95 mL/min. And, it requires dose adjustment or those with a h k h ss r . t k h s rs , h
CrCl o between 50 and 15 mL/min (do not use under CrCl r p Bn P b p s h Pe.
15 mL/min). Note that the most recent available guideline rom
110 Fa mil y med ic in e exa min a t io n & Bo a Rd Review

• a ppr h PeRc r s w s r r h h
HELPFUL TIP: b s r Pe?
c pr ss s k s pr p s hr b
• i p r pr r Pe?
s r , h r rr s
• u rs h a– r ?
r d vt — r !e s -
. c s r pr s r b pr ss s k s r -
h s p s. t hr b s s pr d vt s QUICK QUIZ: ven a c a va l Fil t eRS
s pr p s hr b s r h -
b r r (n n t ) 7 r pr d vt s. t h s
Which statement best describes the use o vena caval lters in
s h b r h r (n n H) 1 22
preventing PE?
p sr q r b r s s , n n H 1 11
A) T ey reduce the risk o PE but only in patients who are
p Pe, nnH 1 5r q r
maintained on anticoagulation.
r. (Ja ma i r m . 2014;174(9):1494–1501.)
B) Retrievable vena caval lters have been shown to have a
short-term advantage while the patient is in the hospital;
they should be removed as soon as possible.
Your patient does well, completes her course o war arin, and C) T ey unequivocally reduce PE risk in both anticoagulated
has no urther episodes over the next 2 years. She develops and nonanticoagulated patients.
gallstones and plans to have an elective laparoscopic chole- D) One need not work-up a patient or a PE in the presence o a
cystectomy. A surgeon colleague sends her back to see you or vena caval lter since they are close to 100% e ective.
a preoperative evaluation. You nd no evidence o cardiac,
pulmonary, or hematologic disease. She is no longer on war- The correct answer is “B.” All o the rest are wrong. All evi-
arin and is doing well. dence suggests that vena caval lters are essentially useless in
preventing PE (e.g., JAMA. 2015:28;313(16):1627–1635). In
Question 3.5.9 Which o the ollowing postoperative man addition, they can break with strut migration to the heart or
agement strategies do you recommend? through the vena cava. 2016 ACCP guidelines recommend
A) Aspirin 81 mg PO daily. against vena caval lters in patients who can be anticoagulant
B) War arin 5 mg PO daily. even aster a recurrent PE. T ey may have some short-term ben-
C) UFH 5,000 units subcutaneously daily. e t or inpatients such as with trauma.
D) Enoxaparin 40 mg subcutaneously daily.
E) No antiplatelet or anticoagulant drugs. CASE 3.6
A 50-year-old male who is a heavy drinker with a history
Answer 3.5.9 The correct answer is “D.” Even or a relatively o squamous cell carcinoma o the neck presents to your
minor surgical procedure where anesthesia is used or 30 o ce complaining o abdominal pain. He has been cough-
minutes or less and the postoperative recovery is usually quick, ing and expectorating bloody sputum and notes a low grade
your patient is at moderate risk or venous thromboembolism. ever, chills, and mild dyspnea starting about 1 week ago.
Her history o PE puts her in a higher risk category, and she He denies nausea, emesis, and chest pain. His squamous cell
requires prophylaxis. O the choices available, enoxaparin would carcinoma was treated with external beam radiation several
be the most appropriate. LMWH and UFH are both acceptable years ago. Examination reveals an a ebrile male in mild dis-
or prevention o DV /PE in the postoperative period, but “C” tress. His vital signs are normal, and his lungs sound clear.
is wrong because UFH must be dosed every 8 to 12 hours rather T e abdominal examination reveals only mild epigastric
than daily. “A” is incorrect. Aspirin is sometimes used postoper- tenderness.
atively, but the dose should be 160 mg/day or greater. Also, com- T e chest x-ray is available or your review (see Fig. 3-5).
pared with heparin and its derivatives, aspirin is less ef cacious Your colleague, who is on call today, walks by and asks i you
in the prevention o thrombus. “B” is incorrect. War arin alone have any admissions or her.
is not appropriate in this setting due to its slow onset o action.
Question 3.6.1 You consider this 50 year old with a cough
HELPFUL TIP: and reply:
th p h h p s r q r pr - A) “Yes. T is gentleman will need the ICU.”
ph s r s hr b b s rs r r s B) “Yes. T is gentleman will need a respiratory isolation
k .ar s b r pr ph s room.”
h p s b s r h r p r . C) “No. I’m sending this gentleman home with metronidazole.”
D) “No. I’ll work-up this gentleman as an outpatient.”

Objectives: Did you learn to . . . Answer 3.6.1 The correct answer is “B.” Because he is expec-
• R z r sk rs r Pe? torating bloody sputum and has a cavitary lesion on chest x-ray
• u rs h r b s p s s s Pe? (right upper lobe), this patient should be admitted to a respiratory
Ch Apt Er 3 • Pu l mo n o l o g y 111

Chest C urther con rms a parenchymal abscess in the right

upper lobe with cavitation and air within the cavity. Bron-
choscopy reveals pus in the airway and extrinsic compression
o the bronchi. A lavage sample is obtained, but biopsies are
not taken due to the clinical impression that this is a lung

Question 3.6.3 What organisms are most commonly

isolated in lung abscesses?
A) Anaerobic bacteria.
B) Aerobic bacteria.
C) uberculosis.
D) Mixed aerobic/anaerobic bacteria.

Answer 3.6.3 The correct answer is “A.” Anaerobes are isolated

most o en, ollowed by mixed anaerobic/aerobic bacteria, ol-
lowed by aerobic bacteria alone (especially staphylococci).

Gram stain o sputum demonstrates Gram-positive cocci and

Gram-negative rods. Cultures are pending. uberculin skin
FIGURE 3-5. P ’s h s -r . test is negative.

Question 3.6.4 What is the most appropriate therapy or

isolation room until tuberculosis is ruled out. He will need this patient?
urther evaluation and possibly intravenous antibiotic therapy, A) Re er or surgical drainage.
both o which may be accomplished during his hospitalization. B) Oral levo oxacin.
“A” is incorrect. T ere is no need to send this patient to the ICU C) Intravenous clindamycin.
based on his current picture. “C” is also incorrect. Metronida- D) Intravenous metronidazole.
zole alone is not an appropriate therapy or this patient even i E) Intravenous ce riaxone.
this is bacterial (see below).
Answer 3.6.4 The correct answer is “C.” Most lung abscesses
Question 3.6.2 What is the best next step in the diagnosis are polymicrobial, but the most important aspect in treatment
o this process? appears to be the use o an antibiotic active against anaerobes.
A) Bronchoscopy. Intravenous clindamycin is the usual choice or lung abscess
B) Sputum cultures. due to its coverage o anaerobes and Streptococcus pneumoniae.
C) Blood cultures. Metronidazole is less e ective, ailing in up to 50% o cases o
D) Chest C . putrid lung abscess. A beta-lactam with beta-lactamase inhibi-
E) Open-lung biopsy. tor (e.g., piperacillin/tazobactam) is another good choice.
Ce riaxone and levo oxacin o er poor coverage o anaerobes.
Answer 3.6.2 The correct answer is “D.” T e chest x-ray dem- Surgical drainage o lung abscesses is needed in only 5% to 10%
onstrates a cavitary lesion in the right upper lobe. Chest C is o cases. Most resolve with just antibiotics.
warranted or urther characterization o the lesion. From his-
tory, examination, and chest x-ray, it is not possible to deter- Objectives: Did you learn to…
mine whether the lesion is an abscess or a malignant process. • R z h pr s r s h s -r ?
An indolent course with low-grade ever is characteristic o • i h s s r s s?
lung abscess. However, the pre-existing squamous cell carci- • d h p p r sp r r s ?
noma has potential to have spread to the lungs, and squamous • m p h bs ss?
cell carcinoma is known to cause cavitations. Culture o sputum
and blood, including evaluation o rst morning sputum or
acid- ast bacilli (AFB), will be an essential part o the assess-
CASE 3.7
ment but may not yield as much in ormation as chest C , and A 53-year-old male is accompanied by his wi e to your o ce
sputum culture should be done in conjunction with cytology and complains o a cough or 6 weeks. It is worse at night and
and Gram stain. Bronchoscopy should be postponed until C any time he lies down. He denies sputum production, short-
results are available. Bronchoscopic biopsy is potentially detri- ness o breath, chest pain, and wheezing. He takes an antacid
mental i the lesion is an abscess since the airway could ood once or twice per day to settle his stomach and notes very bad
with pus i the entire cavity wall is penetrated. heartburn. He smoked three packs o cigarettes per day until
112 Fa mil y med ic in e exa min a t io n & Bo a Rd Review

1 year ago, when he quit “cold turkey.” He takes only hydro- Question 3.7.2 Which o the ollowing is your next step in
chlorothiazide or hypertension and a daily aspirin. He has managing this patient’s cough?
no cardiac disorders. His wi e reports that he snores at night, A) Start a proton pump inhibitor.
and she adds, “He’s always hacking and clearing his throat— B) Start an inhaled steroid.
all night.” T e review o systems is negative. In order to sleep C) Order 24-hour esophageal pH monitoring.
better, he has recently started having a shot (or 2 . . . or 3 . . .) o D) Obtain spirometry.
whiskey be ore going to bed. E) Obtain a chest C .

Question 3.7.1 What is the most likely cause or the cough? Answer 3.7.2 The correct answer is “A.” An empiric trial o an
A) Gastroesophageal re ux. e ective gastric acid-suppressing medication in this symptom-
B) Lung cancer. atic patient is likely to relieve the cough i the diagnosis is accu-
C) Antihypertensive medication. rate. T e ACCP recommends starting therapy with a proton
D) Alcohol abuse. pump inhibitor rather than an H 2-blocker. T e usual anti-re ux
E) Congestive heart ailure (CHF). measures, such as avoiding atty oods, alcohol, and ood be ore
bedtime, should be instituted as well. Prescribers must be aware
Answer 3.7.1 The correct answer is “A.” T is patient appears that sometimes a complete resolution o cough takes months. A
to have a chronic cough that is most likely due to gastroesoph- 24-hour pH monitor (“C”) is invasive and o en not necessary
ageal re ux disease (GERD). He takes antacids and exhibits i an empiric trial o gastric acid suppression resolves the prob-
throat clearing, which can be a subtle sign and is not typically lem. Starting the evaluation o chronic cough with a chest x-ray
identi ed by patients as re ux. In addition, he drinks alcohol is part o the ACCP recommendations, but C scan (“E”) is
at bedtime, urther predisposing to re ux. He has a history o not indicated with a negative chest x-ray. I the cough does not
smoking, which does place him at increased risk or develop- resolve with empiric therapy, spirometry should be considered.
ing a bronchogenic carcinoma, but a lung mass would not be a
common cause or cough. Aspirin is associated with broncho- He does not respond a er 2 months o empiric treatment, and
spasm in some people, but it would not usually present as cough he is becoming more concerned. T e examination is unchanged.
in a patient with no history o asthma. Hydrochlorothiazide is Spirometry is normal with a normal f ow volume loop.
not known to cause cough (although angiotensin-converting
enzyme [ACE] inhibitors are). Also, it is unlikely that symptoms Question 3.7.3 Which o the ollowing management options
would be isolated to nighttime i his cough were medication- is LEAST likely to bene t this patient?
related. A) Combination antihistamine and decongestant.
B) Inhaled corticosteroid.
C) Inhaled beta-2 agonist.
D) Antibiotics.
R b r h a c e h b rs s h 5%
20% p s k h .F rp s h -
Answer 3.7.3 The correct answer is “D.” T is patient has no signs
p h r a c e h b r, br r
or symptoms o sinusitis or bacterial pulmonary in ection, so
h s s rk- p r hr
treating with an antibiotic is inappropriate and unlikely to help.
h. u s ,s p sr s h 1 kb
However, some orm o empiric therapy might be tried. He could
p rs s r 1 h. c h ace h b r
have postnasal drainage without signs on physical examination,
rs r p 6 hs rs r h ace
and empiric therapy with combination antihistamine and decon-
h b r.
gestant may improve the cough. Inhaled corticosteroids and beta-2
agonists are the mainstay o chronic asthma therapy and may help
relieve this patient’s chronic cough. T is patient could yet have
HELPFUL TIP: “cough-variant asthma” despite normal spirometry results.
as p r s s s rb s h-
.S , ’b sh s p r Question 3.7.4 The three most common causes o chronic
r . (a J R sp r c r c r m . 2009;180:809 n cough (cough lasting longer than 8 weeks) are:
e J m . 2009;360:1487.) A) Postnasal drip, asthma, GERD.
B) GERD, COPD, congenital lung disease.
C) Lung cancer, postnasal drip, COPD.
On physical examination, you note a mildly overweight male D) Obstructive sleep apnea, respiratory in ections, asthma.
in no distress. His vital signs are normal. His lungs are clear
to auscultation. T e nasal and oropharyngeal mucosae are Answer 3.7.4 The correct answer is “A.” Epidemiologic stud-
intact, moist, and not inf amed. T e remainder o the exami- ies have demonstrated that most cases o chronic cough are
nation is unremarkable. Chest x-ray shows f attened dia- due to postnasal drainage (o en termed “upper airway cough
phragms but is otherwise negative. You suspect GERD, but syndrome”), asthma, or symptomatic GERD. Most cases o
also entertain other diagnoses. chronic cough seem to have only a single cause, although some
Ch Apt Er 3 • Pu l mo n o l o g y 113


You see a 38-year-old emale in ollow-up or a recent epi-
a u Ri, p r ss s, r rh s, c o Pd rb ,
sh , s s s sode o sinusitis. T e illness has been present or about
6 weeks and has not responded to 2 weeks o appropriate
c hr g eRd , p s s r p, s h , hr s s s, antibiotics. She continues to have intermittent nosebleeds,
r / s r rh s, a c e h b rs, s ph
atigue, arthralgias, low grade evers, and night sweats.
br h s, hr br h s, p s s, s h
wo new complaints have sur aced: she has a cough pro-
u Ri, pp r r sp r r ; c o Pd , hr bs r p r ductive o white sputum and she occasionally expectorates
s s ; g eRd , s r s ph r s s ; a c e, s - quarter-sized clots o blood. She has pleuritic chest pain,
r z .
but denies dyspnea, tobacco use, and cardiac or pulmonary
will have more than one cause. Empiric therapy should be aimed She is a ebrile with a respiratory rate o 16, blood pressure
at these top three causes. O course, in ection (pertussis in par- 120/74 mm Hg, and pulse rate 92 bpm. Her oxygen saturation
ticular), malignancy, and other causes o cough are important to is 98%on room air. T ere is dried blood in the nares, but the
consider—and potentially rule out—as well. oropharynx is clear. Cardiac and pulmonary examinations
T e evaluation o chronic cough should proceed in a logi- are unremarkable.
cal manner. Usually, history and physical examination will nd
the cause. I this is unrevealing, consider a stepwise evaluation
addressing each o the chronic etiologies in able 3-4 in order. I Question 3.8.1 Which initial test is most appropriate?
this still does not give you an answer, consider a methacholine A) Chest x-ray.
challenge test to see i you can reproduce the symptoms that B) Sputum cytologic analysis.
would lead you to a presumptive diagnosis o asthma with nor- C) Bronchoscopy.
mal spirometry. D) Chest C .

l k h rs— r p s hr Answer 3.8.1 The correct answer is “A.” Hemoptysis is alarm-
h s r k .R b r s, ing to the patient and the physician—we hope. A stepwise
sp a c e h b rs ( s b ); h r r s h approach is warranted with chest x-ray as the rst step. Sputum
s h r , z p , s or cytology might help i the suspicion or lung cancer was sub-
sh s ( . ., b r , k s ). stantial, but the yield is likely to be low here. She may eventually
require bronchoscopy i suggested by initial studies. Chest C
is likely to be part o the evaluation, but a chest x-ray should be
Objectives: Did you learn to . . . per ormed rst. Obtaining blood or a CBC is also important,
• R z h s s s hr h? although likely to be normal in the setting o minor hemoptysis.
• e p h hr h?
• d p p r hr h? You obtain the chest x-ray pictured in Figure 3-6.

FIGURE 3-6. P ’s h s -r .
114 Fa mil y med ic in e exa min a t io n & Bo a Rd Review

You get the ollowing laboratory results back: Question 3.8.3 Which o the ollowing is NOT a radiographic
CBC: Leukocytosis, thrombocytosis and normochromic, nding o granulomatosis with polyangiitis?
normocytic anemia. A) Nodules that may be cavitary.
ESR: 70 mm/hr. B) Alveolar opaci cation.
Urine dipstick: Positive or protein, heme, and red C) Pleural opacities.
cells. D) Widened mediastinum.

Question 3.8.2 Which o the ollowing tests will best assist Answer 3.8.3 The correct answer is “D.” A widened medias-
you in the diagnosis o this patient? tinum is not one o the classic ndings in GPA. However, one
A) Antineutrophil cytoplasmic antibody (ANCA). may, on occasion, see hilar adenopathy. All o the other choices
B) Antiglomerular basement membrane antibody. can be ound in GPA. In the patient’s x-ray (Fig. 3-6), a right
C) Antinuclear antibody (ANA). upper lobe mass is easily distinguished. In a young, nonsmok-
D) A and B. ing emale presenting with these symptoms, such a lung mass
E) A and C. should lead to the consideration o GPA or possibly an in ec-
tious process. She is less likely to have a malignant process.
Answer 3.8.2 The correct answer is “D.” T is patient is pre-
senting with the classic triad o granulomatosis with polyangi- HELPFUL TIP:
itis (GPA), a disease o the upper respiratory tract, lower respi- a j r, pr b b h s s , h -
ratory tract, and kidneys. (T is disease was ormerly known as p s s s br h s. t h s s sp r s k rs
Wegener’s granulomatosis. As a response to Wegener’s associa- h r .
tion with the Nazi Party, pro essional bodies and journals have
replaced his name with a descriptive name.) She has some o
the additional signs and symptoms associated with GPA, as T e diagnostic evaluation is in progress. Laboratory tests are
well. Common ndings include: pleuritic chest pain, myalgias, pending, and a chest C is scheduled. You have arranged or
arthralgias, ptosis, ever, weight loss, and purpuric skin lesions, a pulmonologist to see her. When you are on call, the phy-
among others. sician covering the ED calls you to admit her or “massive
ANCA, and especially c-ANCA that is more speci c or hemoptysis.” When you arrive, the patient looks com ort-
GPA, is present in up to 90% o patients with GPA. An ANA able and has normal vital signs. She begins a t o coughing,
is not help ul in diagnosing GPA. An antiglomerular basement expectorating several ounces o bright red blood. Her systolic
membrane antibody (anti-GBM) may be help ul in diagnos- blood pressure alls to 80 mm Hg. Her respiratory rate is 40.
ing Goodpasture syndrome (named or an American patholo- Her work o breathing has increased considerably. T e situa-
gist—not a Nazi—so he gets to keep the eponym). Goodpasture tion does not improve a er 5 minutes o observation, and her
syndrome can be clinically easily con used with GPA; they both O2 saturation is now 83%.
present with respiratory and renal involvement. T us, anti-
GBM antibody will be help ul in di erentiating these two (but Question 3.8.4 Remembering the movie Moulin Rouge
about 10% o patients with Goodpasture syndrome will also (which has nothing to do with this case except or hemop
have GPA—just to add to the con usion). For a partial list o tysis), what is your rst action in this situation?
causes o hemoptysis, see able 3-5. A) Arrange emergent bronchoscopy.
B) rans use 2 units o blood.
C) Per orm endotracheal intubation.
D) Provide bolus IV normal saline.
TABLE 3-5 CAUSES OF h EMOpt YSIS E) ell her, “T e show must go on!”
v s r Pe, s s (g p s r s r ,
Answer 3.8.4 The correct answer is “C.” Massive hemopty-
r ss hp s),
r r s r sis is variably de ned as 100 to 600 mL o blood expectorated
per day, and it can result in hemodynamic compromise and
n p s Br h r , s s s asphyxiation. Quanti cation o the blood loss by the patient is
c ss l p s, rh r hr s usually unreliable. T e main cause o mortality with hemopty-
sis is not hypovolemia but rather asphyxiation rom blood in
c r c HF, r s ss the lungs. As with any patient in acute respiratory distress, the
i s t B, br h s, p , bs ss airway must be controlled rst. T e best choice here is to per-
orm intubation. Since this patient is known to have a poten-
dr s a s, ,s s tial source or bleeding in the right lung, intubation o the le
ms s tr , r b , ps s, h ss mainstem bronchus may protect the le lung rom the blood.
Also, placing this patient on her right side (so that the bleed-
Pe, p r b s ; c HF, s h r r . ing source is dependent) may protect the le lung. I available,
Ch Apt Er 3 • Pu l mo n o l o g y 115

emergent bronchoscopy may allow identi cation o the bleed- C) Bronchogenic carcinoma.
ing site and selective lung intubation. However, bronchoscopy D) Pneumonia.
is not well suited or stopping the hemorrhage. T e most that E) Microscopic polyangiitis.
a bronchoscopist can do is place an endobronchial blocker and
seal o the bleeding lobe. Interventional radiology should usu-
ally be the rst treatment once the bleeding site has been local- Answer 3.9.1 The correct answer is “B.” T e ndings o hilar
ized. Emergent surgery is indicated i the bleeding remains brisk lymphadenopathy and a restrictive pattern on spirometry are
and not responsive to other interventions. Fluid resuscitation most consistent with sarcoidosis. T e chest x-ray ndings do
is important. However, be ore any o these other measures is not support the diagnosis o granulomatosis with polyangiitis.
undertaken, the airway must be protected. Besides, it can’t be “A”—we just did that case (and when would
you see two GPA cases in a row on a test—let alone in your
career?). “E” is incorrect. Microscopic polyangiitis is a systemic
HELPFUL TIP: vasculitis related to GPA, presenting with similar eatures as
i s p r rs h p s hh p- GPA but without granulomatous disease. Bronchogenic carci-
ss s b r h r r noma is unlikely in this relatively young nonsmoker who does
h r b — h h ss h r p s . not demonstrate ndings o carcinoma on x-ray. T e clinical
th b s sph s history is not typical o pneumonia, and chest x-ray shows no
s rpr s h r r h s h gi in ltrate. uberculosis ( B), although not an answer option,
b rs s . a s , s r r should also be considered, and the appropriate history and test-
b r h h h b . ing should be completed. In act, B and sarcoidosis o en pres-
th r r , s r h b s k s s ent in a similar ashion.
h p ssp s.
Question 3.9.2 Which o the ollowing is NOT commonly
associated with sarcoidosis?
A) Hypercalcemia.
T e patient stabilizes in the ICU. You plan to start treatment B) Elevated ACE levels.
or her granulomatosis with polyangiitis. She does better and C) Reduced di usion capacity.
is discharged in 2 days. D) Hypothyroidism.
E) Facial or peripheral nerve palsy.
t h 5- r r r r ss h Answer 3.9.2 The correct answer is “D.” Sarcoidosis is marked
p s s 90%. t h s p s r ss by the presence o noncaseating granulomas. While sarcoid can
r .c ph sph + s r ss b in ltrate the thyroid, it rarely, i ever, causes hypothyroidism.
h b s b . Pulmonary sarcoidosis includes a decreased di usion capacity
and decreased vital capacity. Other laboratory ndings include
hypercalcemia, hypercalciuria, elevated liver and pancreatic
Objectives: Did you learn to . . . enzymes, and elevated ACE levels. Neurologic involvement
• P r r ppr pr p h occurs in up to 5% o patients and requently presents as acial
h p s s? paralysis but may present as any central nervous system lesion.
• R z h j r s s h p s s? Peripheral nerves may also be involved.
• d s r ss hp s?
• i r ss h p s s? Question 3.9.3 Which o the ollowing is NOT ound as a
part o sarcoidosis?
A) Erythema nodosum.
CASE 3.9 B) Myocardial in arction.
A 35-year-old A rican-American emale presents with dys- C) Cardiac arrhythmias.
pnea worsening over the last 2 months. She also complains D) Elevated liver enzymes.
o cough, generalized atigue, and intermittent low-grade E) Vision loss.
evers. She does not smoke. Chest x-ray shows hilar adenopa-
thy and small bilateral pleural e usions. Spirometry is con- Answer 3.9.3 The correct answer is “B.” Sarcoidosis does not
sistent with a restrictive pattern. cause myocardial in arctions. While there is cardiac involve-
ment with sarcoidosis, the mani estations are bundle branch
Question 3.9.1 O the ollowing, which is the most likely block, cardiac arrhythmias, and sudden death. Many organs can
diagnosis? be a ected by sarcoidosis, including the skin, eye (iritis), heart,
A) Granulomatosis with polyangiitis. lung, liver, nervous system—essentially anywhere granulomas
B) Sarcoidosis. orm.
116 Fa mil y med ic in e exa min a t io n & Bo a Rd Review

Question 3.9.4 Which o the ollowing is true about ACE is dullness to percussion and decreased tactile remitus over
levels in sarcoidosis? the right lower lung eld.
A) An elevated ACE level is speci c or sarcoidosis.
B) ACE levels o en correlate with disease severity in sarcoidosis. Question 3.10.1 Based on this patient’s history and physi
C) ACE inhibitors are e ective in the treatment o sarcoidosis. cal examination, what do you expect to nd on chest x ray?
D) All o the above. A) Normal chest x-ray.
B) Cavitary lung lesion.
Answer 3.9.4 The correct answer is “B.” One can ollow ACE C) Pleural e usion.
levels to track the progress o the disease. However, since treat- D) Expanded lung elds.
ment is based on symptoms, ollowing ACE levels is not recom- E) Pneumothorax.
mended. “A” is incorrect. ACE levels may be elevated in silicosis,
miliary B, and asbestosis, among others. “C” is incorrect. ACE Answer 3.10.1 The correct answer is “C.” T is patient’s nd-
inhibitors are not used to treat sarcoidosis. ings suggest pleural e usion. Everything is diminished in pleu-
ral e usion: there is dullness to percussion, decreased breath
T is patient is ound to have only pulmonary sarcoidosis sounds, decreased tactile remitus, and decreased voice trans-
with some mild systemic symptoms. mission. A cavitary lung lesion presents with either a normal
examination or ndings similar to an in ltrate (e.g., crackles,
Question 3.9.5 Which o the ollowing is the best initial increased remitus, and dullness to percussion). Expanded lung
choice or management? elds on chest x-ray are o en seen in patients with COPD or
A) Observation. asthma, and examination ndings include prolonged expiratory
B) Oral corticosteroids. phase, wheezing, and resonance to percussion. Pneumothorax
C) Oral antibiotics. presents with hyperresonance to percussion, decreased breath
D) Inhaled corticosteroids. sounds, and decreased remitus.
E) Methotrexate.
Answer 3.9.5 The correct answer is “A.” T is patient has ch s r r phs h s s r rb r -
apparent pulmonary-limited disease and has minimal sys- r s. H r, h s s r pr b . t h pr s-
temic symptoms. Nearly 50% o patients with sarcoidosis may r bs rb r r s r r .
have spontaneous resolution o their symptoms without treat- wh r r s s h h r r h r s -
ment. In act, treatment may actually prolong the disease pro- h r h rb r r ,s h s p r
cess. I her pulmonary or systemic symptoms worsen or are s rh h r .
causing major li e problems, she should be started on oral
steroids. Systemic corticosteroid therapy is the mainstay o
treatment or sarcoidosis. Methotrexate and other immune- Your suspicions are con rmed. T e chest x-ray shows oblit-
modulating drugs may be employed as well and o er a steroid- eration o the right hemidiaphragm, and the posterior costo-
sparing e ect, but these are not rst-line agents. Evidence or phrenic angle is obscured on the lateral view, consistent with
the use o inhaled corticosteroids is lacking. Antibiotics are pleural e usion. T ere is also a right upper lobe lung mass.
not e ective.
Objectives: Did you learn to . . . Question 3.10.2 Which o the ollowing will provide the
• R z h s s s r s s? most in ormation and guidance or your thoracentesis?
• m p h s r s s? A) Supine chest x-ray.
B) Chest C .
C) Lateral decubitus chest x-ray.
CASE 3.10 D) Chest ultrasound.
A 57-year-old male with no prior medical history comes in E) Apical view chest radiograph.
to clinic with a 1-week history o right rib pain and low-back
pain. T e rib pain is worse with deep breaths and especially Answer 3.10.2 The correct answer is “D.” Prior to per orming
bothers him at night. T ere has been no trauma. He has a thoracentesis, you must know whether the e usion is locu-
lost 20 lb in the last 3 months. He has a cough productive o lated or reely owing. Portable ultrasound has become a vali-
white sputum. He denies any other symptoms. He smokes dated and widely accepted modality to diagnose and access a
one to two packs o cigarettes per day but does not drink pleural e usion. Also, ultrasonography has been ound to be
alcohol. more sensitive or detection o pleural uid than a chest radio-
Vital signs: temperature 36.5°C, pulse rate 95 bpm, blood graph. Chest C is somewhat more sensitive but ar more cum-
pressure 110/70 mm Hg, respiratory rate 16. On room air, his bersome and does not allow a bedside diagnosis and treatment.
oxygen saturation is 96%. T ere is no adenopathy. His lung A decubitus lm, with the a ected side down, would allow you
sounds are clear on the le and decreased on the right. T ere see the e usion “layer out” unless it is loculated but again is less
Ch Apt Er 3 • Pu l mo n o l o g y 117

sensitive. A supine chest x-ray may cause the e usion to “layer TABLE 3-6 CAt EGOr IZAt ION OF pLEUr AL FLUID AS
out” too, but you will not be able to see it as well, which is why AN EXUDAt E Or t r ANSUDAt E
e usions may be missed when a patient is unable to stand or sit
Exuda e h r rz b
upright or his x-ray.
• P r s r pr r > 0.5
Question 3.10.3 Relative and absolute contraindications to • P r s r l dHr > 0.6
• P r ldH r r h 150 / l ( -hr s h pp r
thoracentesis include all o the ollowing EXCEPT: r s r l d H)
A) Herpes zoster in the area o needle placement.
B) Coagulopathy.
C) Diaphragmatic rupture.
D) Positive pressure ventilation. Answer 3.10.5 The correct answer is “D.” Pleural e usions
E) History o recurrent laryngeal nerve injury or compromise. are broadly categorized as exudates and transudates (see
ables 3-6 and 3-7). Such a categorization helps to narrow the
di erential diagnosis. In this case, several elements o the pleu-
Answer 3.10.3 The correct answer is “E.” Absolute contrain-
ral uid are consistent with an exudate. LDH and protein can
dications include chest wall compromise (e.g., burn, cellulitis,
be used to determine whether the pleural uid is transudative
herpes zoster, ruptured diaphragm) and cases where chest tube
or exudative. Per Light’s criteria, a pleural e usion is suggestive
thoracostomy would be more appropriate. Relative contraindi-
o an exudative process i two o any o the ollowing criteria are
cations are poor patient cooperation, coagulopathy, anticoagu-
met: pleural uid LDH > 2/3 the upper limit o normal serum
lation therapy, very small e usions (< 10 mm on decubitus lm
LDH, a pleural LDH:serum LDH ratio o > 0.6, and a pleural
view), positive pressure ventilation, and pleural adhesions.
protein:serum protein ratio o > 0.5. All three o these indicators
point to an exudate in this case. Also, exudative e usions tend to
Question 3.10.4 On ultrasound, the ef usion appears ree have a higher degree o cellularity than transudative e usions.
owing and not loculated. What is the most appropriate With the in ormation given, it is dif cult to determine i the e u-
next step? sion is related to in ection, cancer, or some other process.
A) Re erral or surgical drainage.
B) Place a chest tube to drain the e usion. T e pleural f uid cytology comes back negative. T e patient’s
C) Per orm an ultrasound-guided diagnostic thoracentesis at symptoms and examination have not changed. Repeat radio-
the bedside. graph still shows an upper lobe mass.
D) Order two pizzas, one or you and one or the patient (you
have both had a long day and are hungry). Question 3.10.6 What is the most appropriate next step in
approaching this pleural ef usion?
Answer 3.10.4 The correct answer is “C.” T e patient has a A) Await pleural uid culture results.
relatively large pleural e usion. Ultrasound-guided thoracen- B) Per orm bedside chest tube drainage o the e usion.
tesis is a good rst step in evaluating this e usion. Ultrasound C) Re er or surgical evacuation o the e usion.
guidance is quickly becoming the standard o care as it has D) Re er or bronchoscopy.
been shown to decrease complications o pneumothorax as well E) Place a chest tube or chemical pleurodesis.
as the number o unsuccess ul clinical attempts or “dry taps.”
Re erral to a thoracic surgeon may eventually be necessary, but
this would not be the rst step. Placing a chest tube into an e u- TABLE 3-7 CAt EGOr IZAt ION OF pLEUr AL EFFUSIONS
sion is not recommended at this point, and the diagnostic study BY CLASS (t r ANSUDAt IVEVEr SUS EXUDAt IVE)a
should be obtained rst.
Type o Ef usion Potential Causes
Ultrasound-guided thoracentesis is success ul in obtaining tr s s s H r r , rrh s s, phr
f uid. T e f uid is amber and cloudy, with a pH 7.3, lactate s r , s s, ,
p r b s , r h r
dehydrogenase (LDH) 800 IU/L, glucose 65 mg/dL, total pro-
tein 5.5 g/dL, WBC 1,300/mm3, RBC 50,000/mm3. Serum stud- e s s Br h r , s
ies done the same day include LDH 155 IU/L, glucose 99 mg/dL, p s , s h ,p ,
and total protein 7.0 g/dL. Cytology, Gram stain, and culture t B, h h r ,p r s, s ph
r p r , s r s s s
o the pleural f uid are pending.
(rh r hr s, Sj r s r ),
r , r s( r r ,
Question 3.10.5 Which o the ollowing is the most accurate r , h r ), h r
statement regarding the pleural uid analysis? r h r h r p ,p r
b s
A) T e uid is due to in ection.
B) T e uid is due to cancer. Note: H r r p r b s s
C) T e uid is a transudate. r s s s.
D) T e uid is an exudate. a
S exudate r r t b 3-5. e r h s s r s .
118 Fa mil y med ic in e exa min a t io n & Bo a Rd Review

Answer 3.10.6 The correct answer is “D.” T e e usion is clearly

exudative, and the patient appears to have a lung mass. Biopsy CASE 3.11
o the lung mass via bronchoscopy is indicated. A negative pleu- A 60-year-old male presents to the ED or a cough. His symp-
ral uid cytology does not rule out lung cancer. Positive cytol- toms began with a cold 2 weeks ago, and the other symp-
ogy indicates advanced stage lung cancer. Chest tube drainage toms have improved, but the cough has persisted. He has
o a pleural e usion is not recommended except under extraor- mild production o white sputum with no hemoptysis. T e
dinary circumstances. Intermittent thoracentesis is pre erred patient denies evers, night sweats, chills, and weight loss.
and has lower morbidity. Surgical evacuation o the uid would He’s had no chest pain or dyspnea. He smokes one pack o
be indicated i the patient were symptomatic, the e usion was cigarettes per day, works in construction, and does not have
loculated and/or related to in ection. I the e usion grows, or is a regular doctor. In act, with some pride, he says, “I haven’t
drained and recurs, it may respond to pleurodesis. Otherwise, seen a doctor in over 30 years.” On physical examination, you
pleurodesis is not indicated at this time. nd a t-appearing male in no acute distress. His vital signs
are normal. His lung sounds are diminished bilaterally, but
HELPFUL TIP: the remainder o the examination is unremarkable. While
P s h p r s s r k breathing ambient air, the patient’s oxygen saturation is 94%.
b r s r r s h r s z You obtain a chest x-ray, which is shown in Figure 3-7.
s r s b b h sp .l - r s
h p r s r b k. Question 3.11.1 Your next step is to:
A) Prescribe a 5-day course o azithromycin.
B) Re er the patient to a pulmonologist.
Now that you have gained expertise with ultrasound o a C) Order a high-resolution C scan o the chest.
pleural e usion, your colleague sends you a patient that has D) Have the patient return to you in 3 months to repeat a chest
a pleural e usion on chest x-ray. Your colleague asks you x-ray.
whether you could “tap” the f uid or him as he does not eel E) Reassure the patient and have him return as needed.
com ortable with the portable ultrasound. Also, he has a tee
time in 30 minutes. Answer 3.11.1 The correct answer is “C.” T e chest x-ray in
Figure 3-7 shows a single nodule in the right lower lobe. T e
Question 3.10.7 On ultrasound, you quickly visualize the nodule is round, less dense than bone, and appears to be > 1 cm
chest and see a septated and loculated pleural ef usion. in diameter. T ese are sometimes called “coin lesions.” T ere are
What is the best next step? no other abnormalities. T e most appropriate next step in the
A) Return the patient back to his doctor—the e usion is too evaluation is to order a high-resolution C scan o the chest.
small to access. reatment with azithromycin is inappropriate in this setting, as
B) Per orm ultrasound-guided needle thoracentesis. this patient has no signs o pulmonary in ection on examination
C) Re er to a thoracic surgeon. or chest x-ray. Re erral to a pulmonologist is premature with-
D) Place a small-bore chest tube. out rst investigating the nodule by C scan. Delaying urther
E) Head to the gol course with your colleague. Nothing you
can do here.

Answer 3.10.7 The correct answer is “C.” A loculated and sep-

tated pleural e usion can very o en be seen in empyema and
evacuation usually requires surgical intervention. T oracentesis
would unlikely be success ul and would expose the patient to
an unnecessary procedure a er which he would still need to see
a surgeon. Placing a chest tube blindly into a loculated pleural
e usion is unsa e. T at procedure should be done under visual-
ization; most commonly, video-assisted thoracic surgery would
be utilized.
Objectives: Did you learn to . . .
• R z h hs r ph s f s
p r s ?
• l s p s p r s ?
• n rr h r ssb s p r
f s?
• d h p r r s h r p
h r s s?
• d h p r r h s b r ? FIGURE 3-7. P ’s h s -r .
Ch Apt Er 3 • Pu l mo n o l o g y 119


Size (mm) Low Risk Patients High Risk Patients
4 n - p F - p 12 hs. i h ,
rh r

> 4–6 F - p 12 hs. i h , i - p c t 6–12 hs

rh r h 18–24 hs h

> 6–8 i - p c t 6–12 hs i - p c t 3–6 hs

h 18–24 hs h h 9–12 24 hs h

>8 F - p cts r 3, 9, 24 S s r -r sk p s
hs. d r s h
c t , Pet , / r b ps

Notes: t h s s pp r s p rs s 35 rs r r.
l -r sk p sh r bs hs r s k h rk r sk rs. H h-r sk
p sh hs r s k r h rk r sk rs.

imaging and evaluation is also inappropriate since 15% to 75% I the diameter is < 8 mm, the risk o cancer is low. When the
o solitary pulmonary nodules (SPNs) ≥ 8 mm are ultimately diameter is ≥ 3 cm, the SPN is now re erred to as a “pulmonary
diagnosed as cancer. mass” and is highly likely to be cancerous. SPN > 3 cm in diam-
eter should be considered cancer until proven otherwise.
Question 3.11.2 Which o the ollowing is NOT considered a T e Fleischner Society has published a set o widely accepted
benign pattern o calci cation on CT scan? recommendations regarding ollow-up o single pulmonary
A) Di use, homogeneous calci cation. nodules noted on C chest that are < 8 mm in diameter (see
B) Central calci cation. able 3-8).
C) Laminar calci cation.
D) Spiculated, irregular calci cation.
E) “Popcorn” calci cation. HELPFUL TIP:
th r s h s (b s ) s r -
Answer 3.11.2 The correct answer is “D.” We are accustomed s r SPn s. S c h s . 2013 m r; 143:840
to thinking o calci ed nodules as being benign, but that is not h p r . P r s b-s s
always the case. Irregular, spiculated calci cation is not reas- <5 - p s h r k b
suring. T e other options are considered indicative o a benign (< 2% r sk s k r). t h r s -
lesion. wo patterns on C are relatively speci c or cancer: a r h p r h r sk h r :
scalloped border and the corona radiata sign, which is com- h p://r r . s p . / r/s r -p -
posed o ne linear strands extending out rom the nodule. r - -r sk. H s ss h rp .
Question 3.11.3 All o the ollowing are use ul to help assess
the risk o cancer in a patient with an SPN EXCEPT:
A) Smoking status. Later that week, your patient returns with his C scan in
B) Age. hand. His cough is somewhat better (therapeutic C scan
C) Diameter o the nodule. radiation therapy . . . you know, like those C scans in Cali-
D) Gender. ornia that were cooking people’s brains accidentally?). You
review the C scan with him. It shows a round, smooth nod-
Answer 3.11.3 The correct answer is “D.” Determining the ule measuring 2 cm in diameter and located in the periphery
probability o cancer in patients with an SPN is an inexact sci- o the right lower lobe. T ere are no calci cations in the nod-
ence. T e risk o cancer is generally assessed as low, interme- ule and no other abnormalities.
diate, or high based on patient and radiograph characteristics.
Although men are slightly overrepresented in lung cancer diag- Question 3.11.4 Which o the ollowing is the most appro
noses, this is generally thought to be due to greater smoking priate next step?
rates in men and to occupational hazards. Gender itsel does not A) Re erral or bronchoscopy.
help to risk-strati y patients with an SPN. Smoking increases the B) High-resolution C scan every 3 months.
risk o an SPN being cancer, with greater use increasing the risk C) Chest x-ray every 3 months.
o cancer. As with most cancers, increasing age is associated D) Bone scan.
with a higher risk. T e diameter o the nodule is also important. E) Re erral to a thoracic surgeon.
120 Fa mil y med ic in e exa min a t io n & Bo a Rd Review

Answer 3.11.4 The correct answer is “E.” T is patient needs a C) “Here have him spit in this cup, and I’ll send his sputum or
biopsy. T ere are several actors that put your patient at higher cytology.”
risk o having a malignant cause or the SPN, including his D) “Nah, we don’t recommend lung cancer screening at this
age and tobacco use. T ese put him into an intermediate- to time.”
high-risk category or cancer. Although the nodule is smooth
on C , its size is > 8 mm and there are no calci cations. T is Answer 3.11.6 The correct answer is “B.” In 2013, the USP F
patient should be re erred or transthoracic ne-needle biopsy issued a grade B recommendation or annual lung cancer
or open biopsy. “A” is tempting but incorrect. Bronchoscopy is screening with low-dose C scan in adults aged 55 to 80 years
insensitive in the peripheral lung, especially when the lesion who have a 30 pack-year smoking history and currently smoke
is relatively small. “B” and “C” are also wrong here but are or have quit within the past 15 years. Screening should be dis-
appropriate in other settings. In this case, repeat imaging over continued once a person has not smoked or 15 years or devel-
time may delay a diagnosis o malignancy. Without symptoms ops a health problem that substantially limits li e expectancy or
o bone pain or con rmation that the SPN is a cancer that the ability or willingness to have curative lung surgery. T ese
might metastasize to bone, a bone scan will have a very low recommendations are based on the National Lung Screening
yield. rial that showed that or every 1,000 people who got screening
or lung cancer, 3 ewer died o lung cancer because o screen-
Your patient returns rom the surgeon much relieved. Fine- ing. About 300 people need to be screened to save one li e rom
needle biopsy proved the SPN to be a hamartoma. Now your lung cancer. Patients should be given the risks/bene ts o lung
patient wants to quit smoking or good, and he thinks that he cancer screening since approximately 365/1,000 patients will
will need some assistance. You recommend nicotine replace- have a alse-positive result (usually because o a benign pul-
ment products and bupropion, but your patient claims to monary nodule) that leads to more C scans (extra radiation),
have had an allergic reaction to bupropion. Fortunately, you more invasive procedures (biopsies and surgeries), and patient
know o an e ective alternative (unless he is a homicidal stress and anxiety. Con used yet? Don’t worry, the Ameri-
maniac . . . it happens you know). can T oracic Society has developed a patient decision guide
ound at http://www.thoracic.org/patients/patient-resources/
Question 3.11.5 To assist with tobacco cessation, you pre resources/decision-aid-lcs.pd . Your patient’s brother can read
scribe which o the ollowing? the 20 pages while on his next smoke break! Just kidding. It
A) Varenicline. is important to stress that this lung cancer screening should
B) Fluoxetine. not take the place o e orts to stop smoking! O note, “A” and
C) Olanzapine. “C” are incorrect because neither plain chest radiographs nor
D) Metoprolol. sputum cytology have been shown to improve lung cancer
E) Clonidine. mortality.
Answer 3.11.5 The correct answer is “A.” Randomized trials Objectives: Did you learn to . . .
have demonstrated the e ectiveness o the nicotine partial ago- • w h r sk rs h SPn ?
nist, varenicline (Chantix M). T is FDA-approved medication • d p p r SPn ?
appears to be at least as e ective as bupropion as an aid to smok- • a ss s p hs k ss ?
ing cessation. Fluoxetine and other selective serotonin reuptake • l r h r sks/b f s rs r h
inhibitors have not demonstrated a bene t. In schizophrenic ppr pr p p p ?
patients, the use o atypical antipsychotic medications may aid
in smoking cessation when compared with typical antipsychot-
ics. Clonidine is sometimes used to help patients who are with-
CASE 3.12
drawing rom narcotics, and it may have some limited role in A 74-year-old male presents to your ED or weakness, cough,
smoking cessation but is not very e ective. Depression, very and atigue. His wi e relates an incomplete recovery since
vivid dreams or nightmares, aggressive behavior, etc., are a well- his myocardial in arction last year. He continues to have
described side e ect o varenicline, and your patients should be poor appetite and listlessness, and she thinks that he may be
in ormed o that prior to prescribing the drug. depressed. He is short o breath and con used. His wi e says
that yesterday he developed a ever, chills, and a new cough
As you are walking out o your patient’s room, your patient productive o white sputum. His past medical history is oth-
says, “Hey Doc, my brother smokes too, is there a test you can erwise remarkable or a cholecystectomy. He is taking aspi-
do to make sure he doesn’t have lung cancer?” rin, metoprolol, and atorvastatin.
Vitals: temperature 39°C, respiratory rate 30, pulse 90
Question 3.11.6 You respond: bpm, blood pressure 140/80 mm Hg. Oxygen saturation on
A) “Sure, I’ll put in an order or him to get an outpatient chest room air is 90%. He is thin, pale, and oriented to person only.
x-ray.” T e lung examination is remarkable or rales in the le lower
B) “ ell him to make an appointment and we will discuss the eld, with dullness to percussion and increased tactile remi-
risks/bene ts o low-dose C scan.” tus. T e remainder o the examination is normal.
Ch Apt Er 3 • Pu l mo n o l o g y 121

T e chest x-ray shows a le lower lobe in ltrate. Other Question 3.12.2 Based on patient speci c characteristics
laboratory data currently available: hemoglobin 12.4 g/dL, and your knowledge o causative actors involved in pneu
WBC 14,100/mm3, platelets 340,000/mm3, creatinine 1.9 mg/ monia, which o the ollowing is LEAST likely to be the
dL, BUN 50 mg/dL, and normal electrolytes, troponin, and agent causing this patient’s in ection?
CK. An ECG shows normal sinus rhythm. A) Mycoplasma pneumoniae.
B) S. pneumoniae.
Question 3.12.1 What is your next step in managing this C) Haemophilus in uenzae.
patient’s medical condition? D) Pseudomonas aeruginosa.
A) Place a chest tube on the le .
B) Per orm chest C . Answer 3.12.2 The correct answer is “D.” When a pathogen is
C) Administer inhaled bronchodilators. identi ed in adult community-acquired pneumonia, it is usually S.
D) Administer parenteral antibiotics. pneumoniae. In act, S. pneumoniae makes up 40% to 60%o all cases
E) Per orm intubation and mechanical ventilation. o community-acquired pneumonia in the elderly. Nontypeable
H. in uenzae composes about 5% to 10% o cases. Mycoplasma is
Answer 3.12.1 The correct answer is “D.” Given the clinical implicated in 5% o all cases o pneumonia in adults, and it is more
picture and chest x-ray ndings, the patient most likely has common in young adults. P. aeruginosa pneumonia is uncommon
community-acquired pneumonia. T ere ore, the administra- in healthy elders and more likely to occur in patients with serious
tion o parenteral antibiotics is the best choice. “A” is incorrect. underlying lung disease or immunode ciency. Approximately 5%
Since there is no e usion, a chest tube would be useless. “B” o patients or more are in ected with multiple agents.
is incorrect. C is not required in this straight orward case o
pneumonia. “C” is incorrect. T e patient is not wheezing and Question 3.12.3 On the basis o your assessment o his risk,
there is no indication or bronchodilators at this time. As or you decide to admit this patient to the hospital. An IV is in
“E,” since your patient’s respiratory status is stable, he does not place. Which o the ollowing IV antibiotic regimens do you
require intubation. choose?
A) Penicillin.
HELPFUL TIP: B) Azithromycin.
R b r h s p ss b “ p ” rs s C) Penicillin and gentamicin.
“ p ”p b r r ph. d b s D) Azithromycin and ce riaxone.
r h r p r - q r p E) Piperacillin/tazobactam and cipro oxacin.
h r r ph pp r .a p r s s
s b r s p p s Answer 3.12.3 The correct answer is “D.” T e 2007 In ec-
pp r s .n h r s k tious Disease Society o America / American T oracic Society
r r ph pp r . (IDSA/A S) guideline or pneumonia recommends that or
community-acquired pneumonia treated in the hospital set-
ting the optimal antibiotic regimen must o er good coverage
HELPFUL TIP: o S. pneumoniae, H. in uenzae, and atypical organisms such
th p s r s p p r as Mycoplasma and Chlamydia species. Most S. pneumoniae
s r h h r r p h bacteria are resistant to penicillin and about 20% to 30% are
p .H r, s s b rs h b resistant to macrolides such as azithromycin. T ere ore, these
r b r .l k p (h p:// r . agents should not be used alone in the treatment o pneumo-
s . /p r / p/10675. ). nia in hospitalized patients. Gentamicin has no activity against
S. pneumoniae but has a role in P. aeruginosa in ections. Ce ri-
axone o ers good Gram-negative coverage and activity against
HELPFUL TIP: S. pneumoniae. Azithromycin covers atypical organisms. For
a s p rb ss - ss r r- these reasons, “D” is the best choice. An alternative regimen
sp s p hp —h would be monotherapy with a respiratory uoroquinolone, such
“c u RB-65.” c h , , h? H r r h r b s: as moxi oxacin or levo oxacin. T e combination o piperacil-
C s
(b s sp s r s r - lin/tazobactam with cipro oxacin is reserved or patients with
p rs , p , r ). more severe pneumonia, requiring ventilation and ICU care.
Ur (Bu n ) > 20 / l.
R sp r r r > 30 br hs/ . Initial blood cultures grow S. pneumoniae. Sputum Gram
B pr ss r < 90/60. stain and culture are negative. T e patient initially does well
a > 65 rs. and de ervesces a er 2 days o IV antibiotics. However, on
P s h s r 0 r1h r sk day 3, he again spikes a ever. He looks moderately ill. Your
h r r s r p - examination reveals increased dullness to percussion on the
. le . T ere is no jugular venous distention (JVD) or periph-
eral edema. T e radiograph is shown in Figure 3-8.
122 Fa mil y med ic in e exa min a t io n & Bo a Rd Review

FIGURE 3-8. P ’s h s -r .

Question 3.12.4 The most likely diagnosis at this point is: D) Prescribe amoxicillin/clavulanate.
A) Anaerobic abscess. E) Re er or bronchoscopy.
B) Development o resistant S. pneumoniae.
C) Parapneumonic e usion. Answer 3.12.5 The correct answer is “C.” T ere are no clear
D) ransudate secondary to heart ailure. guidelines regarding ollow-up chest x-ray in patients who had
E) Drug-induced transudate. pneumonia. T e British T oracic Society published recommen-
dations in 2007 where it advised repeating chest x-ray in 6 weeks
Answer 3.12.4 The correct answer is “C.” T e most likely prob- in patients with a smoking history. T e reason or that recom-
lem in this patient is a parapneumonic e usion. “A,” an anaero- mendation is a chance that the in ltrate would obscure an under-
bic abscess, is unlikely given that there are no air/ uid levels lying malignancy. T ose over age 50 should also have ollow-up
and the act that the uid appears to be in the pleural space. “B” x-ray. Bacteremic pneumococcal pneumonia has been associated
is unlikely. Development o resistance should take more than with very slowly clearing x-rays, up to 3 to 5 months in some
3 days, especially since this patient is on two drugs. “D” is cases. T us, repeating the chest x-ray in 2 weeks is unlikely to
unlikely given that this patient does not have a history o heart show resolution, so “B” is incorrect. In elderly patients, the chest
ailure, is ebrile, and has no JVD, etc. “E” is unlikely. None o x-ray takes longer to normalize than in younger patients.
the drugs that he is on is known to cause pleural e usions. T e patient is clinically doing well, and does not require treat-
ment or a persistent pulmonary in ection, so “D” is incorrect.
You place a chest tube to drain the pleural e usion ( ree f ow- Chest C (“A”) and bronchoscopy (“E”) would give more in or-
ing on ultrasound) and continue the current antibiotic regi- mation, but in the absence o systemic symptoms, such as weight
men. T e patient does well and is discharged 1 week later on loss, persistent cough, hemoptysis, or ever, they are not indicated.
clarithromycin a er sensitivities conclude that his organism It is important to consider the act that this “in ltrate” may rep-
is susceptible to that drug. resent a neoplastic process i it does not resolve within several
Six weeks a er the onset o illness, he returns or ollow- months.
up to ensure clearing o the chest x-ray. He is eeling well. He
is alert and oriented, and his lung examination is now nor- HELPFUL TIP:
mal. T ere is no lymphadenopathy in the neck or supracla- e h s (b r , sp
vicular areas. T e x-ray still shows le lower lobe in ltrate, r , .), s s
unchanged in size rom the initial x-ray. T e pleural e usion 50% s s p . t h s, r s s
has resolved. p r . Sp r s r b h r p
r s s s p s hp ,
Question 3.12.5 Which o the ollowing is the most appro 30% p s h p r b
priate next step in the evaluation and management o this pr sp .B r s r r
patient? p b r s r s -
A) Chest C . s r h sp z p s. i p ss b , b -
B) Chest x-ray in 2 weeks. r sb r h r p .
C) Chest x-ray in 6 weeks.
Ch Apt Er 3 • Pu l mo n o l o g y 123

Your patient returns a week later looking ill. He has dyspnea, HELPFUL TIP:
ever, and worsening cough. His temperature in the o ce is S r s b h p h sp z p h
39°C, and he has a new in ltrate on chest x-ray. - q r p h r s r
s ppr ss , r hr s r s
Question 3.12.6 This situation is best described as: ’ h r b s( r r -
A) Community-acquired pneumonia. s r s). S l . 2015;385(9977):1511–
B) Double pneumonia. 1518 r hs h ( , h h sp ).
C) Hospital-acquired pneumonia.
D) Healthcare-associated pneumonia.
E) riple pneumonia.
In one o li e’s unny little coincidences, the next day you
Answer 3.12.6 The correct answer is “D.” T e 2007 IDSA/ diagnose this patient’s 36-year-old healthy son with a com-
A S guidelines de ne high-risk pneumonia based on setting. munity-acquired pneumonia. He has a ever, cough, and le
Healthcare-associated pneumonia is de ned as pneumonia lower lobe in ltrate on chest x-ray, but he is hemodynami-
occurring in a nonhospitalized patient who has had exten- cally stable. You determine that he’s t or outpatient man-
sive healthcare contact (meaning IV therapy or chemotherapy agement.
within the last 30 days, residence in a nursing home, attendance
at a hemodialysis center within the last 30 days, or 2 or more Question 3.12.8 Which o the ollowing drug regimens is
days in an acute care hospital in the last 90 days). Your patient appropriate or the treatment o this patient in the outpa
meets this de nition due to his recent hospitalization. “C,” tient setting?
hospital-acquired pneumonia, is one that develops 48 hours A) Cephalexin 250 to 500 mg PO QID or 10 days.
or more a er admission to a hospital and did not appear to B) Penicillin V 250 mg ID or 10 days.
be brewing at the time o admission. T e guidelines also dis- C) Clarithromycin 500 mg BID or 10 days.
tinguish ventilator-associated pneumonia, which occurs in D) Doxycycline 100 mg BID or 10 days.
patients 48 hours or more a er endotracheal intubation. “B” E) C or D.
and “E” are ake oils. Sorry!
Answer 3.12.8 The correct answer is “E.” T e treatment o
Question 3.12.7 Now that he has healthcare associated community-acquired pneumonia requires coverage o “typical”
pneumonia, you order the appropriate antibiotic regimen and “atypical” organisms. Neither “A” nor “B” covers atypical
consisting o : organisms. Guideline-recommended choices or the outpatient
A) Linezolid and amphotericin B. treatment o community-acquired pneumonia include doxycy-
B) Ce epime. cline and macrolides such as clarithromycin. Additional options
C) Gentamicin and vancomycin. include the respiratory uoroquinolones such as moxi oxacin,
D) Cipro oxacin. gemi oxacin, or levo oxacin. However, respiratory uoroqui-
nolones should not be used in all cases. T e IDSA/A S consen-
Answer 3.12.7 The correct answer is “B.” Since he has sus guidelines recommend that respiratory uoroquinolones
received antibiotics in the last 90 days, an anti-pseudomonal be reserved or patients with serious underlying disease (e.g.,
cephalosporin is indicated. Depending on circumstances, COPD, diabetes, immunocompromised states). O the appro-
other antibiotics may be added to broaden empiric coverage. priate regimens, doxycycline and erythromycin are the least
For example, i there are high levels o resistance to Gram- expensive, but erythromycin is associated with a high rate o
negative bacilli in the area, add an aminoglycoside. I MRSA gastrointestinal intolerance.
is suspected, add linezolid or vancomycin. I legionella is
likely, add a uoroquinolone. In this scenario, “A” is incorrect
because it does not cover pseudomonas and a ungal in ec-
2007 id Sa /a t S s r r p -
tion is not likely in this immunocompetent patient. T e same
s h - q r p r h
is true o “C.” “D” may be arguable but is not the pre erred
r 5 s. H r, pr r s -
empiric choice according to the 2007 IDSA/A S guidelines.
r , h sh s b br r
Most important: know your local resistance patterns and your
48 72 h rs sh h r h h
patient’s speci c characteristics.
r r s b :h r r > 100 bp ,
r sp r r r > 24, s s b pr ss r < 90
H ,o2 s r < 90% r r, P o 2 < 60 H
HELPFUL TIP: r r, b r k , s .
Pr p p h b rs H2-b k rs r ss Sh h p h r h h s r r ,
h r s r sk p .S p h h r r b h r p s ( h p
. s h h h !).
124 Fa mil y med ic in e exa min a t io n & Bo a Rd Review

Objectives: Did you learn to . . .

sr sh b p r h p s. t h r s
• R z h pr s - q r
h sh s h s h j r s r
p r p p p s?
pr vil i s sr s b r
• d r h ppr pr sp s r p h
6 8 l /k pr b h p s.
- q r p ?
i ,p s h sh r c o Pd q k
• i p p r r -
p h p r h h h r -
q r p ?
s. v p s h bs r s s -
r r r h .
CASE 3.13
While you are covering the ED, a 60-year-old emale comes
in by ambulance. She is unresponsive, and her husband states Your patient is on assist-control mode o ventilation. A
that he ound her 30 minutes ago surrounded by bottles nasogastric tube, 2 IVs, and a bladder catheter are in place.
o pills and an empty bottle o vodka. She has a history o She was given IV N-acetylcysteine. Her blood pressure has
COPD, hypertension, osteoarthritis, and depression. T e improved to 112/67 mm Hg, and her oxygen saturation
EM s brought in her pill bottles, which include lorazepam, is 99%. Her chest x-ray shows an endotracheal tube ter-
acetaminophen/hydrocodone, hydrochlorothiazide, aspirin, minating 3 cm above the carina and no in ltrates. T irty
and sertraline. Only a ew tablets are le in the bottle o minutes a er you intubated her, with the ventilator rate at
hydrochlorothiazide. She is wearing a nonrebreather ace- 14 breaths/min, FiO2 100%, and tidal volume at 400 mL,
mask with 50% oxygen. Her respirations are shallow with you obtain another ABG: pH 7.35, PaCO2 45 mm Hg, PaO2
a rate o 8. T e remainder o her vitals: temperature 36°C, 130 mm Hg. She takes 6 to 8 spontaneous, assisted breaths,
blood pressure 90/50 mm Hg, and pulse rate 90 bpm. Oxygen while the ventilator provides the remaining breaths. She
saturation is 88% and increases to 94% with some assisted appears to be per using her periphery well.
breaths. One nurse is obtaining a blood gas while another
gives naloxone. You decide that this patient cannot protect Question 3.13.2 Your next action is to:
her airway and choose to intubate her. A) Decrease the tidal volume to allow or permissive hypercapnia.
T e blood gas drawn just be ore intubation shows pH 7.16, B) Increase the tidal volume to achieve a pH o 7.45 to 7.50.
PaCO2 60 mm Hg, PaO2 40 mm Hg. C) Reduce FiO2 while maintaining oxygen saturations at or
above 90%.
Question 3.13.1 These ndings imply which o the ollow D) Change to pressure support ventilation.
ing processes?
A) Metabolic acidosis. Answer 3.13.2 The correct answer is “C.” Your patient is per-
B) Metabolic alkalosis. using well, and her PaO2 and measured oxygen saturation are
C) Respiratory alkalosis. much improved. You should now decrease the FiO2, with the
D) Mixed metabolic/respiratory acidosis. goal being to achieve an FiO2 o less than 60% while maintain-
E) Mixed metabolic/respiratory alkalosis. ing adequate per usion and oxygen saturation. An FiO2 o 100%
is somewhat toxic and can lead to airway injury. “A” is incorrect.
Answer 3.13.1 The correct answer is “D.” T e pH is acidotic However, permissive hypercapnia (the CO2 may be allowed to
(< 7.4). In a patient whose baseline PaCO2 is not known to you, rise to > 80 mm Hg as long as the patient tolerates it) may be
you might assume her PaCO2 is usually 40 mm Hg, which is the use ul in ventilated patients with COPD, ARDS, or asthma.
accepted normal or most patients. But remember that you still need to maintain oxygenation.
I the acidosis is purely due to acute respiratory changes and “B” is incorrect. Your patient is doing reasonably well with her
CO2 retention, a rise in PaCO2 o 10 should be accompanied slightly acidotic pH, which has corrected very quickly. It may be
by a all in pH equal to 0.08. In this case, the change in PaCO2 inadvisable to attempt to increase her pH beyond 7.40, as she
is 20. So, 20/10 × 0.08 = 2 × 0.08 = 0.16 resulting in a pH o may develop respiratory alkalosis that can then lead to cardiac
7.4 − 0.16 = 7.24. arrhythmias. Because o her low respiratory rate, she should
However, this patient’s pH is measured at 7.16, lower than remain on some type o assisted volume-cycled ventilation.
expected or a pure respiratory acidosis presenting acutely. T us, Pressure support ventilation, as its name implies, only aug-
you can determine that the acidosis is both metabolic (perhaps ments patient-triggered breaths with increased airway pressure.
rom lactic acidosis rom hypoper usion) and respiratory.
HELPFUL TIP: P r ss h p r p s ppr h h
i s r h s r pr p - p h r h pr r s co 2 b p -
s h r sp r r s r ss s r / r s pH ( s 7.1) r r pr -
j r (a Rd S/a l i) pr vil i ( r- pr r s
j r ). i s r h h r h s pr h p r r bs r .
Ch Apt Er 3 • Pu l mo n o l o g y 125

Question 3.13.3 In this patient, which o the ollowing venti

lator management techniques will unequivocally decrease
RSBi s h pr rs s ss b .i
her FiO2 requirement?
s b r sp r r r b
A) Increase the respiratory rate.
rs h p s pr ss r s pp r
B) Increase the positive end-expiratory pressure (PEEP).
h s s (pr ss r 5–10, PeeP 5–8). F r
C) Decrease the tidal volume.
p ,p br h 20 sp r h
D) Addition o inhaled nitric oxide (NO).
500 l h s RSBi 20/0.5 = 40. P
br h 34 sp r h 210
Answer 3.13.3 The correct answer is “B.” wo standard tech-
l h s RSBi 34/0.21 = 161 s b s r
niques are usually employed to improve a patient’s oxygenation:
b b .
increasing FiO2 and PEEP. PEEP maintains positive pressure
in the airways at the end o expiration. Its use increases lung
compliance and decreases ventilation/per usion mismatching, HELPFUL TIP:
resulting in better oxygenation. Since FiO2 > 60% over peri- ic u s s h r h o R; b s
ods longer than 48 hours may result in oxygen toxicity, PEEP h ic u rr h h r r sk r .d b r
may be employed to reduce the need or high levels o FiO2. “A” p s b r - b . th r s p r
and “C” are incorrect. Increasing respiratory rate or tidal vol- pr r s ss ic u b sh
ume will cause increases in minute ventilation, which reduces h p 15% ic u p s r q r r - b
PaCO2, but has little e ect on PaO2. Decreasing minute ventila- sp pr rs s ss b .
tion, through decreased respiratory rate or tidal volume, causes
CO2 retention and increased PaCO2. “D” is incorrect. Nitric
oxide has been shown to improve oxygenation in select patients HELPFUL TIP:
with severe pulmonary hypertension and ARDS, but its use is m ( r h p )s b -
not appropriate in this patient. p r sp r r r b . t h s, p rs
20 br hs/ r h r 400 l /
You ollow the patient during her hospitalization. T e next br h r s = 20 × 400 =
day she is more alert and is able to ollow commands. Her 8l/ .
ventilator requirements have decreased. You consider extu-

Question 3.13.4 All o the ollowing parameters predict a Objectives: Did you learn to . . .
poor outcome or attempted weaning rom ventilation • R z r sp r r / b s s?
EXCEPT: • c p pH h s r sp r r s s?
A) Minute ventilation supplied by ventilator is < 10 L/min. • i s h ppr pr rs -
B) PaO2 < 55 mm Hg while on FiO2 > 35%. s?
C) Rapid shallow breathing index (RSBI) o 140. • i p p s ?
D) Physical examination ndings o increased respiratory • w p r h r?
e ort.

Answer 3.13.4 The correct answer is “A.” Preparing to with-

CASE 3.14
draw a patient rom mechanical ventilation—typically called A 52-year-old male smoker presents or a 3-month history o
weaning or liberation—relies considerably on judgment, but productive cough. He reports multiple episodes o pneumo-
a ew objective parameters can be help ul. In general, the nia, but he appears healthy now. Chest x-ray is unremarkable.
patient to be liberated must be awake, alert, and coopera- Chest C shows enlarged peripheral airways with thickened
tive. She should have reasonably good oxygenation on a lower airway walls in the lower lobes bilaterally. Sputum culture
FiO2, have PEEP < 8 cm H 2O, and be able to generate adequate grows several types o bacteria, including P. aeruginosa.
inspiratory pressures. Minute ventilation rom the ventilator
o less than 10 L/min is associated with greater success with Question 3.14.1 Which o the ollowing do you recommend
weaning. as initial therapy?
Poor prognostic indicators include a minute ventilation A) Corticosteroids.
rom the ventilator > 10 L/min, PaO 2 < 55 with FiO 2 > 35%, B) Antibiotics.
and RSBI (see Help ul ip) > 105. Patients with poor cardio- C) Chemotherapy.
pulmonary reserve or who have signi cant underlying disease D) Supplemental oxygen.
may also have dif culty weaning. Allow patients a period o E) Wedge resection o the a ected lung tissue.
breathing on their own (e.g., a -piece) be ore extubating. T is
way, i the patient ails, you can simply hook her back up to the Answer 3.14.1 The correct answer is “B.” T is patient’s nd-
ventilator. ings are consistent with the diagnosis o bronchiectasis, a
126 Fa mil y med ic in e exa min a t io n & Bo a Rd Review

chronic in ammatory disease o the medium-sized bronchi. O the ollowing tests, which is the most likely to con rm or
Appropriate initial therapy consists o prolonged courses alter the diagnosis?
o antibiotics, usually 2 weeks o a narrow-spectrum anti- A) Spirometry, di using capacity, lung volumes.
biotic ollowed by reassessment. Doxycycline, amoxicillin, B) Spirometry, ABG, di using capacity.
clarithromycin, amoxicillin/clavulanate, and trimethoprim/ C) ABG, di using capacity, lung volumes.
sul amethoxazole are o en used. Respiratory quinolones D) ABG, lung volumes, chest C .
demonstrate some limited use in patients with Pseudomonas.
Patients should be directed to discontinue tobacco use and The correct answer is “A.” T is case demonstrates a commonly
take inhaled bronchodilators. Resection o the a ected lung seen phenomenon: patients who smoke and have dyspnea are
tissue may be necessary, but should not be the initial therapy. assumed to have obstructive lung disease, particularly emphy-
Supplemental oxygen therapy is used i oxygenation is poor. sema. However, pulmonary unction tests are required to make
Chemotherapy and prolonged oral corticosteroids are not the diagnosis o obstructive disease. Furthermore, this patient’s
used to treat bronchiectasis. chest x-ray shows increased interstitial markings in the lower
lung elds suggesting interstitial lung disease. T is disease pro-
cess is associated with a restrictive pattern on pulmonary spi-
HELPFUL TIP: rometry. However, lung volumes and di using capacity will
P s h br h ss r r h provide a more complete picture. T us, spirometry, di using
r r b s pr - capacity, and lung volumes would allow you to make the diag-
rb s. o r s r b r- nosis. In interstitial lung disease, spirometry shows a FEV1/FVC
h pr /s h z , k ratio > 0.7, a decreased di using capacity, and decreased total
h s b s r h rs 10 14 s h lung capacity (the hallmark o restrictive lung disease). ABG is
h. t h ss hs r s unlikely to help di erentiate restrictive rom obstructive lung
s . disease, so options “B” through “D” are not correct.

Question 3.14.2 In most adults with bronchiectasis, its HELPFUL TIP:

cause is: th s p , s s r b dl co , s
A) Genetic. h s s s s: ph s , rs
B) Pseudomonas in ection. s s ( . ., s r , s, p r r -
C) obacco smoking. ,p r r r ss h s r ,
D) Allergic bronchopulmonary aspergillosis (ABPA). p r br s s), P s sp , p -
E) Unknown. r s r s s .a s s
d l c o —s h b rh r sh s
Answer 3.14.2 The correct answer is “E.” T ere are limited b r r h dl co .
data regarding the etiology o bronchiectasis, but many condi-
tions and environmental exposures seem to have an association.
In most patients, no cause is identif ed. Children are more likely HELPFUL TIP:
than adults to have an identi ed etiology o their bronchiecta- dl co b r s b p r h rrh ,
sis, and the most common causes in kids are oreign body aspi- p h , ss b s , - -r h r r
ration, cystic brosis, and gastroesophageal re ux. Identi ed sh , sh , h r r ( r s p -
etiologies in adults include those mentioned or children and r h s).
pulmonary in ections, ABPA, COPD, rheumatic diseases, and
cigarette smoking.
Objectives: Did you learn to . . . QUICK QUIZ: Pu l mo n a Ry in Fec t io n S
• i f s ss h br h s s?
• tr p h br h s s? A 72-year-old woman you admitted to the hospital or pneu-
monia is having worsening dyspnea and hypoxemia. She is
decompensating despite 3 days o antibiotic therapy with intra-
QUICK QUIZ: d ySPn ea venous levo oxacin. According to her husband, the couple
had been working on their Iowa arm, and made a trip to an
A 75-year-old gentleman presents to your of ce with emphy- old barn to collect manure a week be ore the patient developed
sema diagnosed elsewhere. He reports dyspnea on exertion a er a cough and ever (so this is not hypersensitivity pneumonitis
1 to 2 blocks. He smokes 10 cigarettes per day and does not have nor organic toxic dust syndrome). T e barn was noted to be
underlying cardiac disease. Physical examination is remarkable the home o numerous birds. Her respiratory rate is 32, and her
or ne crackles in both lung bases. Chest x-ray shows increased oxygen saturation is 89% on 5 L/min o oxygen by nasal can-
interstitial markings in the lower lobes. He has no pulmonary nula. Chest x-ray reveals a di use interstitial in ltrate, enlarged
unction testing on record. mediastinal nodes, and normal heart size.
Ch Apt Er 3 • Pu l mo n o l o g y 127

Which o the ollowing is the most likely culprit or the cause o orm o hypersensitivity pneumonitis. However, they need not
her current illness? be present in the subacute and chronic orms o the disease.
A) S. pneumoniae. So, based on symptoms, this could be hypersensitivity pneu-
B) H. in uenzae. monitis. However, the radiologic ndings o hypersensitivity
C) Coxiella burnetii. pneumonitis would include interstitial lung disease, rather than
D) Histoplasma capsulatum. central bronchiectasis. T us, this is not likely hypersensitivity
E) Blastomyces dermatitidis. pneumonitis.
“B” and “D” are incorrect. Note that she has no signi cant
The correct answer is “D.” T e case described here is classic or constitutional symptoms that might be more typical o acute
an environmental exposure to a large dose o Histoplasma organ- eosinophilic pneumonia or bacterial in ection. You would also
isms. Histoplasmosis is o en transmitted by bird or bat drop- expect an in ltrate on the chest C . “E” is incorrect. Churg–
pings. Histoplasma occurs most commonly in the Mississippi Strauss vasculitis is characterized by transient patchy intersti-
and Ohio River valleys, causing a sel -limited disease in most tial in ltrates, ever, weight loss, elevated sedimentation rate,
persons. Patients who have Histoplasma in ection requently de- abnormal liver enzymes, and a peripheral blood eosinophilia
velop calci ed mediastinal lymph nodes a er resolution o the > 1,000 cells/µL. T is is o en related to using an oral steroid
in ection. Diagnosis can be made by urinary antigen or broncho- and a leukotriene inhibitor simultaneously. It seems, but isn’t,
scopic biopsy. T e bacterial causes are unlikely to be important related to inhaled steroids because once the patient is on a ste-
actors here, as she was on a broad-spectrum antibiotic or 3 days roid inhaler, the oral steroid is usually tapered unmasking the
with no improvement. C. burnetii, the agent causing Q ever, is vasculitis. Extrapulmonary mani estations distinguish Churg–
rare and tends to a ect workers exposed to resh animal material, Strauss rom other eosinophilic pulmonary conditions.
such as placentas. Blastomyces is ound in the same regions as
Histoplasma, but the site o exposure tends to be more moist, un- Question 3.15.2 Which o the ollowing would be the next
like the dry environment inside a barn. We all have granulomas best step in con rming the diagnosis?
rom histoplasmosis on CXR in Iowa. A) Sputum cultures.
B) ransbronchial biopsy.
CASE 3.15 C) Methacholine challenge.
D) Allergy skin testing or Aspergillus species.
A 42-year-old emale comes to your o ce with a history o E) p-ANCA.
asthma that has been di cult to control. She relates symp-
toms that have been worsening over the last 4 to 6 weeks. Answer 3.15.2 The correct answer is “D.” Most but not all o
She received two courses o oral corticosteroids during that the ollowing criteria ( able 3-9) need to be present in order to
time. Her symptoms improved with this therapy but quickly make the diagnosis o ABPA. ransbronchial biopsy is unneces-
returned a er completing the steroids. She denies ever, sarily invasive, and the other tests will not help to con rm the
chills, and night sweats, but complains o a chronic cough diagnosis.
productive o brownish-colored sputum. She is a homemaker
in a suburban area and has no pets. Physical examination Question 3.15.3 The most appropriate treatment or this
reveals wheezing throughout all lung elds but is otherwise patient with ABPA would include which o the ollowing?
normal. Laboratory evaluation includes CBC with increased A) Antibiotics.
eosinophils, normal C-reactive protein, and an elevated IgE B) Oral corticosteroids.
level o 1250 ng/mL. A high-resolution C scan o the chest C) Leukotriene receptor antagonist.
reveals central bronchiectasis. D) Itraconazole.
E) Inhaled ipratropium bromide.
Question 3.15.1 What is the most likely diagnosis?
A) Hypersensitivity pneumonitis. Answer 3.15.3 The correct answer is “B.” Oral corticosteroids
B) Acute eosinophilic pneumonia. are the treatment o choice or ABPA. Patients are typically
C) Allergic bronchopulmonary aspergillosis (ABPA). treated or several months with tapering doses rather than short
D) Bacterial pneumonia.
E) Churg–Strauss vasculitis.
Answer 3.15.1 The correct answer is “C.” T is patient’s history Br ONCh OpULMONAr Y ASpEr GILLOSIS (ABpA)
points to the diagnosis o ABPA, which is characterized by the
• as h
presence o severe asthma, brownish mucus plugs, peripheral • c r br h ss
eosinophilia above 10%, elevated serum IgE, and central bronchi- • e s r i e > 1,000 / l
ectasis. IgE elevation is required to be greater than 1,000 ng/mL. • i sk s r Aspergillus
“A” is unlikely but a bit tricky. First, there is no history o • e s r -sp f i e / r i g Aspergillus fumigatus
• P r ph r b s ph > 10%
exposure to a causative agent. Second, let’s ocus on symptoms.
• P r f r s
Constitutional symptoms—o en ever—are present in the acute
128 Fa mil y med ic in e exa min a t io n & Bo a Rd Review

courses o steroids. Serum IgE levels and chest x-rays are used to C) Change classes o antihistamines.
monitor response to treatment. Please note that “D” is incorrect, D) Re er or allergy evaluation, including percutaneous
and azoles are not the mainstay therapy in ABPA. T e goal o aeroallergen skin testing.
treatment is suppression o the immune system responding to E) Recommend a high ef ciency particulate air lter or the
the ungal antigen. T ere are studies that show bene t o adding home.
an anti ungal agent as a steroid-sparing agent. However, there
are risks associated with concomitant use o steroids and azoles, Answer 3.16.2 The correct answer is “C.” Although all o the
namely, marked adrenal suppression. Hence, oral corticoste- above choices may provide relie or allergic symptoms, the best
roids should be your rst choice. rst step would be to try changing the class o antihistamines.
Antihistamines (and NSAIDs or that matter) are grouped into
Objectives: Did you learn to . . .
classes based on chemical structure. One class may be help ul
• i h pr s a BPa ?
or a patient when another class does not work.
• d s r p h a BPa ? T e other choices are suboptimal. Without skin testing,
avoidance measures may be needless, costly, and ine ective.
CASE 3.16 Skin testing alone (“D”) would not immediately improve her
A 16-year-old emale comes to your o ce with complaints o symptoms, and you would still need to do something with
sneezing spells, itchy watery eyes, and nasal congestion or therapy (we hope) while waiting 3 months to see an allergist.
the past 2 years. T ese symptoms are worse during the spring Allergen-impermeable encasements (“A”) are currently recom-
and all and when she plays with her cat. She denies any other mended or patients with dust mite allergy. Although lters
constitutional symptoms and has no other past medical his- (“E”) are o en recommended or pet allergies, the data regard-
tory. She has tried over-the-counter loratadine without relie . ing their e ectiveness in reducing allergic symptoms is contra-
She has lived in the same residence or the past 6 years and dictory. opical decongestant sprays (“B”) are an inappropriate
denies any other environmental exposures. Her examination choice secondary to the addictive nature o these medications
reveals pale nasal mucosa and swollen nasal turbinates bilat- and the risk o causing rebound symptoms. Removing a pet
erally. Her lungs and skin are clear. rom the bedroom may reduce—but not eliminate—allergen
exposure. Further evaluation should be per ormed prior to rec-
ommending any such li estyle modi cations. Another reason-
Question 3.16.1 You are not clear i this is allergic rhinitis able option would be a trial o intranasal corticosteroid. Finally,
or nonallergic rhinopathy (previously known as vasomo you could also put an allergen impermeable encasement around
tor rhinitis). The most ef ective way to determine i this is the cat . . .
allergic is to:
A) Do a methacholine challenge test. Your patient’s 17-year-old brother is in the next examination
B) Do a Hansel stain o nasal mucus. room. He is a Boy Scout who just returned rom a backpack-
C) Check overall IgE levels. ing trip in the our corners area o New Mexico, Arizona, Col-
D) Per orm a nasal mucus electrophoresis to visualize allergic orado, and Nevada (. . . did you catch that? I you know your
bands. geography, you know one o those is wrong). He has noted
E) Wa hot peppers under her nose . . . see what happens. myalgias, ever, and chills. He knows that you are reviewing
pulmonary medicine or your upcoming Board Examina-
Answer 3.16.1 The correct answer is “B.” T e best way to tell tion, so he presents to your o ce complaining o dyspnea
i this is allergic is to do a Hansel stain o the nasal mucous. that has been getting markedly worse over the past several
T is will show eosinophils i it is allergic. I this is nonallergic days. He has no URI symptoms such as coryza, rhinorrhea,
rhinopathy, eosinophils will be absent. I it is in ectious, there ear pain, etc. He has noticed nausea, vomiting, and diarrhea
will likely be a predominance o neutrophils. “A” is incorrect. A with severe abdominal pain. His respiratory rate is 40 with
methacholine challenge test is help ul in diagnosing asthma, not an oxygen saturation o 88%. (“See,” he says, “I told you I’m
allergic rhinitis. Neither “C,” IgE levels, nor nasal mucus electro- sick.”) You place him on nasal oxygen and order a chest x-ray,
phoresis have any use here (and nasal mucus electrophoresis has which shows bilateral pulmonary edema.
no use anywhere that we know o . . . and it is disgusting). IgE
is only elevated in 40% o patients with allergic rhinitis. Does Question 3.16.3 Based on the epidemiology and chest x ray
anyone ever actually do a Hansel stain? Probably not, but once appearance, your best guess at this point in the disease is:
again, this is or the Board Examination, not real li e. A) Plague.
B) Coccidiodomycosis.
Question 3.16.2 The Hansel stain shows eosinophils. “Eureka!” C) Hantavirus rom Sin Nombre (No Name) strain.
you shout. Which o the ollowing would be the most appro D) Noncardiogenic pulmonary edema rom smoking para-
priate next step in managing her symptoms? quat (you never know what is going on at those Boy Scout
A) Recommend allergen-impermeable encasements or camps).
mattress and pillow. E) Ischemic cardiomyopathy rom cocaine use (you never
B) Use topical decongestant sprays. know what is going on at those Boy Scout camps).
Ch Apt Er 3 • Pu l mo n o l o g y 129

Answer 3.16.3 The correct answer is “C.” T is is a typical his-

B j s h r s r hs r s; s h
tory and physical examination or hantavirus. T e absence o h s p s r s r r r b b h p .
URI symptoms, the presence o GI symptoms, and the noncar- th pr h rs h s s .
diogenic pulmonary edema are all symptoms/signs o hantavi-
B r s r r h p p (b
rus. In act, it may present as an acute abdomen. It is spread
s h ).
by aerosolization o mouse excrement or urine. “B” is incor-
rect. Although coccidiodomycosis, “Valley Fever,” is ound in d s - b - s sh h
h s r .i rs s s.
the same geographical region, it presents with lower respira-
tory symptoms, a thin walled cavitary lesion, erythema nodo- d s h s r s r c o Pd . t h
sum (10%), and eosinophilia. Coccidiomycosis is generally a r s p r b .
low grade, subacute process that lasts weeks to months. It does F r c o Pd p s, r s p
not cause noncardiogenic pulmonary edema. “A,” pneumonic p s h sh r - h br h r ( . .,
plague, while also ound in the same area, causes high ever, b r ) h - h br h r
bloody sputum, pleuritic chest pain, and develops over hours to ( . ., r p ) s p s r r .
days. It can be rapidly atal i not recognized and treated within i s p ss b r b r “ p ”r
the rst day. “D” and “E” are wrong or so many reasons that we “ p ”p b -r .
won’t bother to enumerate them here, but you never do know wh s h r p , k s r h r s
what goes on at camp. s r q r s h
ss h br h h p h h sp .
Question 3.16.4 Laboratory ndings suggestive o hantavi
rus include all o the ollowing EXCEPT:
A) T rombocytopenia. BIBLIOGRAPHY
B) Leukocytosis with a le shi .
American College o Chest Physicians. . Pulmonary Medicine
C) A lymphocytic predominance. Board Review. Northbrook, IL: ACCP; 2009;167–173.
D) An immunoblast count < 10%.
Annema J , et al. Endoscopic ultrasound added to medias-
tinoscopy or preoperative staging o patients with lung
Answer 3.16.4 The correct answer is “D.” In act, thrombocy- cancer. JAMA. 2005;294:931–936.
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constitute the so-called diagnostic triad in a patient with appro- ing cessation. Cochrane Database Syst Rev. 2007;24(1):
priate clinical ndings. Immunoblasts are the most immature CD006103.
cell in the lymphocyte line (they still enjoy scribbling on walls Celli BR, et al. T e body-mass index, air ow obstruction, dys-
and drink irresponsibly). Overall, case atality rate o hantavi- pnea, and exercise capacity index in chronic obstructive
rus is up to 50%. Care is supportive. Extra-corporeal membrane pulmonary disease. N Engl J Med. 2004;350:1005–1012.
oxygenation may be used in seriously ill patients. T ere is o en Daniels JM, et al. Antibiotics in addition to corticosteroids or
an oliguric phase that needs care ul management to prevent acute exacerbations o chronic obstructive pulmonary
uid overload. T is can be problematic because patients are disease. Am J Respir Crit Care Med. 2010;181:150–157.
o en hypotensive and there is a proclivity toward giving them Decramer M, et al or Global Initiative or Chronic Obstructive
uids. Lung Diseases. Global strategies or the diagnosis, man-
agement, and prevention o chronic obstructive pulmo-
Objectives: Did you learn to . . . nary disease: GOLD executive summary. 2015. Available
• a ss ss r r rh s? at http://www.goldcopd.com; accessed August 31, 2015.
• d s h r s ? Ege MJ, et al. Exposure to environmental microorganisms and
childhood asthma. N Engl J Med. 2011;364:701–709.
Gibson PG, et al. Allergic bronchopulmonary aspergillosis.
Semin Respir Crit Care Med. 2006;27(2):185–191.
Clinical Pearls Irwin RS, Madison MJ. T e diagnosis and treatment o cough.
N Engl J Med. 2000;343(23):1715–1721.
a r co 2 b s sp p s ss
Zodang W, et al. Outpatient patient treatment in patients with
co 2 r p r s r sp r r s s.
acute pulmonary embolism. J T romb Haemost. 2011;9:
a sb s h s ss h s s s 1500–1507.
r r b s p r h o2 h h r Lacasse Y, et al. Clinical diagnosis o hypersensitivity pneumo-
r s s r. v s s sh r ss. nitis. Am J Respir Crit Care Med. 2003;168:952–958.
a s s sp r r s c o Pd . o 55% h s Laszlo G. Standardisation o lung unction testing: help ul
s s s s s p sh c o Pd ; h guidance rom the A S/ERS ask Force. T orax. 2006;61:
r s h r r s r h r sp . 744–746.
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American T oracic Society consensus guidelines on the
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adults. Clin In ect Dis. 2007;1(44, Suppl 2):S27–S72. 564.
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tinuing-Medical-Education-(CME)/Focus-On/Focus-On– nary disease: prevalence and risk actors. Ann Int Med.
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Allergyand Immunology
Wendy Shen and Jason K. Wilb r
Question 4.1.2 With regard to radioallergosorbent testing
CASE 4.1 (RAST) or allergic rhinitis, which o the ollowing is true?
A 15-year-old girl has a history o acute di culty breathing A) RAS is less expensive than traditional skin testing.
when playing basketball. Her symptoms include inspiratory B) RAS is more sensitive than traditional skin testing.
wheezing/stridor, increased respiratory rate, throat tight- C) RAS has a limited role in testing those with allergic rhinitis.
ness, and chest discom ort. Premedication with adequate D) Antihistamine use is a contraindication to the use o RAS .
doses o albuterol has no e ect.
Answer 4.1.2 The correct answer is “C.” RAS will be nega-
Question 4.1.1 What is the most likely diagnosis? tive in up to 25% o those with a positive skin test, has poorly
A) Exercise-induced asthma. reproducible results, and is more expensive. T us, skin testing
B) Gastroesophageal re ux disease. remains the procedure o choice or identi ying allergens. RAS
C) Musculoskeletal chest pain. can be used i skin testing is unavailable.
D) Hyperventilation.
E) Vocal cord dys unction. Question 4.1.3 Which o the ollowing medications does
NOT need to be discontinued prior to aeroallergen skin
Answer 4.1.1 The correct answer is “E.” Vocal cord dys- testing?
unction (VCD) is one o the most common asthma mim- A) Intranasal steroid spray.
ics. Patients with VCD present with hoarseness, coughing, B) Atenolol.
dyspnea, and loud inspiratory wheezing/stridor, along C) Amitriptyline.
with other symptoms mentioned above. Pulmonary unc- D) Cyproheptadine.
tion testing indicates airway obstruction due to an extra- E) Azelastine nasal spray.
thoracic component. It appears that paradoxical inspiratory
vocal cord adduction causes air ow restriction at the level Answer 4.1.3 The correct answer is “A.” Intranasal steroid
o the larynx, resulting in a attened inspiratory loop on sprays do not need to be discontinued prior to skin testing as
ow–volume diagram. VCD presents a diagnostic challenge, they do not inter ere with immediate-type hypersensitivity
and o en leads to unnecessary treatment o asthma. In this reactions. T ey are not antihistaminic in nature, as opposed
patient, a β 2-agonist was ine ective, even though she displays to amitriptyline, cyproheptadine, or azelastine, which may all
symptoms with exertion. T is argues against answer “A.” T e blunt dermal reactivity. Although azelastine is administered
distinction between VCD and asthma may be less clear in as a nasal spray, its administration may inter ere with skin test
other patients, since the two disorders sometimes coexist. reactivity within 2 days o usage. Beta-blockers, such as ateno-
T e clinical history does not support the diagnoses o gas- lol, have been shown to a ect skin test reactivity and should be
troesophageal re ux disease, musculoskeletal chest pain, or avoided in patients undergoing skin testing.
Aeroallergen skin prick and intradermal testing reveals posi-
You make the diagnosis o VCD. However, the patient also tive reactions to dust mites, cat, ragweed, and tree pollens.
complains o rhinorrhea, itchy eyes, sneezing, and itchy nose. T e patient relates that she gets considerable nasal conges-
Because you realize that we need to discuss it in this book, tion and has tried over-the-counter decongestants with no
you kindly re er her or allergy testing (thank you!). relie .


Question 4.1.4 Which o the ollowing interventions would more severe systemic reactions to immunotherapy. Patients
provide the most relie or her nasal symptoms? should be treated with an alternative antihypertensive during
A) Diphenhydramine 25 mg PO BID. immunotherapy. T e current practice parameters or aller-
B) Montelukast 10 mg PO QHS. gen immunotherapy recommend that emergency epinephrine
C) Intranasal steroid spray daily. should be readily available or the treatment o systemic aller-
D) Ipratropium bromide nasal spray BID. gic reactions associated with immunotherapy. o monitor or
E) Getting rid o the cat. No one should have a cat. T ey are these immediate reactions, patients should be observed in the
evil. of ce setting or at least 30 minutes a er immunotherapy shots
are administered. Based on studies o seasonal symptom scores,
Answer 4.1.4 The correct answer is “C.” Intranasal corticoste- it is generally recommended that allergen immunotherapy be
roids would provide the most relie in this patient by addressing continued or 3 to 5 years.
nasal congestion in addition to the other nasal symptoms men-
tioned. Although antihistamines are very help ul in relieving Your next patient has a history o ragweed and grass allergy.
nasal symptoms such as rhinorrhea, nasal itching, and sneezing, He states that he is “allergic” to needles. Accordingly, you
they are generally not as e ective or nasal congestion. Likewise, decide to use sublingual (SL) desensitization instead o sub-
montelukast is a leukotriene modi er, which is approved or the cutaneous (SQ) routes. Luckily, there are FDA-approved sub-
treatment o allergic rhinitis, but studies suggest that intranasal lingual preparations or desensitization to ragweed, imothy
steroids are superior. In addition, nasal steroids are not systemic grass and a 5-grass combination.
(although a bit may be absorbed). Ipratropium is mainly e ec-
tive or rhinorrhea only, while nasal saline irrigations promote Question 4.1.6 Which o the ollowing is true regarding SL
thinning o nasal secretions and drainage, but neither predict- desensitization?
ably improves nasal congestion. As to “E,” yes, cats are evil and A) It is more e ective than SQ desensitization.
shed. But as amily doctors we are supposed to be accepting o B) It is overall sa er than SQ desensitization; there are ewer
our patient’s quirks. adverse systemic reactions than with SQ desensitization.
C) It can cause airway obstruction by causing tongue and phar-
ynx edema.
HELPFUL (AND REALLY COOL) TIP: D) It is well studied as a combination therapy with SQ desensi-
Nasal steroids also seem to improve oc lar symptoms. tization.
Whether some o the dr ets p the nasolacrimal E) B and C.
d cts or is otherwise aerosolized into the eye is nclear.
Obvio sly, do not p t nasal steroids directly in the eye. Answer 4.1.6 The correct answer is “E.” SL desensitization
For moderate-to-severe aller ic rhinitis, combination o can causes ewer anaphylactic reactions but can cause airway
intranasal steroid and intranasal antihistamine is more obstruction rom local edema. “A” is incorrect. T e great major-
e ective than either alone. ity o studies show that SQ desensitization is more e ective than
SL desensitization. “D” is also incorrect. T e use o SL therapy
in combination with SQ desensitization is contraindicated and
may increase the rate o anaphylactic reactions. As a nal note,
She returns to you a year later, having tried intranasal ste- most patients who require desensitization need desensitization
roid sprays and high-dose antihistamines, without gaining to more than just imothy grass or ragweed or the 5-grass com-
signi cant relie . She has instituted appropriate avoidance bination limiting the use ulness o SL therapy. Patients are o en
measures during the interim (there goes the cat), also with- also allergic to tree pollen, animal dander, and other allergens
out improvement in symptoms. You recommend allergen that cannot be treated with SL therapy.

Question 4.1.5 All o the ollowing statements are true

regarding allergen immunotherapy EXCEPT: HELPFUL TIP:
A) Patients should carry emergency epinephrine to all immu- Beta-blockers sho ld be stopped in patients with a his-
notherapy shot appointments. tory o anaphylaxis i possible. Beta-blockers ampli y
B) It is unnecessary to stop beta-blocker therapy prior to start- anaphylaxis and make it more di ic lt to treat.
ing immunotherapy.
C) Patients should be observed in the of ce or at least 30 min-
utes a er immunotherapy injections.
D) At least 3 years o immunotherapy should be given to avoid Objectives: Did you learn to . . .
recurrence o symptoms. • Reco nize symptoms o vocal cord dys nction?
• Reco nize symptoms o aller ic rhinitis?
Answer 4.1.5 The correct answer is “B.” It has been shown that • Provide appropriate mana ement or aller ic rhinitis?
patients taking beta-blockers may be at increased risk o having • Describe the role o imm notherapy in treatin aller ic rhinitis?


Reaction Type Mechanism Clinical Features Timing
Type I—Immediate Anti en expos re ca ses cross-linka e o I E antibodies Anaphylaxis Less than an ho r
that are bo nd to s r aces o mast cells and basophils, An ioedema a ter expos re
with s bseq ent release o mediators s ch as histamine. Bronchospasm
u rticaria

Type II—Cytotoxic I g or I M antibodies are directed a ainst anti ens on g ra t rejection At least 5 days b t
the individ al’s own tiss es, and s bseq ent complement Hemolytic anemia sometimes many
activation leads to cell destr ction. Ne tropenia weeks a ter expos re

Type III—Imm ne complex I g or I M anti en–antibody complexes orm and deposit Localized arth s reaction 1 week or more a ter
within blood vessels and tiss es, ca sin complement Ser m sickness expos re
activation and ne trophil recr itment, ltimately res ltin
in tiss e dama e.

Type IV— Delayed Anti en expos re to sensitized T cells ca ses a reaction. Contact dermatitis 24–72 ho rs a ter
Stevens–Johnson syndrome expos re

The correct answer is “A.” Celery is so boring; it can’t even

QUICK QUIZ: ALLERg IC REACTIONS cause an allergic reaction in those with latex allergy! Symptoms
o oral allergy syndrome can include oral pruritus with or with-
A 52-year-old man with common variable immunode ciency out angioedema o the lips, tongue, palate, and posterior oro-
(CVID) receives his rst in usion o intravenous immunoglobu- pharynx. Cross-reactivity has been reported between:
lin (IVIG) therapy. en minutes into the in usion, he complains • Ragweed antigens and the gourd amily and banana.
o dif culty breathing and generalized pruritus. • Birch pollen allergy may result in sensitivity to apple, carrots,
parsnips, celery, hazelnuts, and potatoes.
Based on the traditional classi cation o hypersensitivity
• Latex- ruit cross-reactivity may occur with banana, avocado,
reactions, which o the ollowing best categorizes this patient’s
passion ruit, kiwi, and chestnut, but not celery. Your patient
should be warned about these potential reactions.
A) ype I—Immediate hypersensitivity reaction.
B) ype II—Cytotoxic reaction.
C) ype III—Immune complex reaction.
D) ype IV—Delayed-type reaction. HELPFUL TIP:
The vast majority o patients who report penicillin (and
The correct answer is “A.” Based on the clinical history and other) aller ies are not tr ly aller ic. In the case o peni-
timing o the above event, you should suspect an immediate cillin, 0.5% o those with reported penicillin aller y had
hypersensitivity reaction ( ype I). ype I reactions typically skin reactions and less than 10% had any reaction to a
occur within seconds to minutes a er exposure to the o end- ll dose o penicillin. Many patients misinterpret an ad-
ing agent and are due to cross-linkage o IgE antibodies that are verse reaction (s ch as na sea) as an aller y.
bound to sur aces o mast cells or basophils, with subsequent
release o mediators such as histamine. Pruritus, urticaria,
angioedema, laryngeal edema, and possible generalized ana-
phylaxis can occur. o see why ypes II to IV are incorrect, re er
There is essentially no cross-reactivity between penicil-
to able 4-1 or de nitions o the immunologic reaction types.
lin and third- eneration cephalosporins. As lon as the
patient did not have tr e anaphylaxis, eel com ortable
QUICK QUIZ: CAN I HAVE THAT BANANA OR NOT? sin these dr s in penicillin-aller ic patients.

A slightly deranged patient o yours has a serious latex allergy

and wants to play “ ruit roulette.”
You tell her that all o the ollowing may be associated with
cross-reactivity in latex allergic patients EXCEP : A 57-year-old man with chest pain is scheduled or an elective
A) Celery. cardiac catheterization. You remember that the patient has a
B) Banana. history o generalized urticaria with lip and tongue angioedema
C) Avocado. shortly a er receiving contrast dye or a C scan several years
D) Kiwi. back.

Which o the ollowing interventions should be recommended Answer 4.2.1 The correct answer is “B.” Corn is not o en
or this patient prior to undergoing the planned procedure? implicated in ood allergies (a good thing too, since we are writ-
A) Use o higher-osmolality radiocontrast media i possible. ing this in Iowa, surrounded by corn). Although many oods
B) Give a test dose o radiocontrast media and proceed as usual are potentially antigenic, the great majority o ood allergies
i testing is negative. involve only a ew oods. Studies have shown that eight oods
C) Administration o prednisone and diphenhydramine as pre- account or 93% o reactions, and these oods are, in order o
medications. requency: egg, peanuts, milk, soy, tree nuts, sh, crustacean,
D) Percutaneous and intradermal skin testing with radiocon- and wheat. Although these ood allergies may be outgrown,
trast media. sensitivity to peanuts, tree nuts, sh, and crustaceans tend to
E) Desensitization procedure or radiocontrast media. be li e-long.

The correct answer is “C.” Anaphylactoid reactions to radio-

contrast material are typically non–IgE-mediated; however,
The peak incidence o ood aller ies occ rs aro nd
they look very similar to a ype I immunologic reaction and
a e 1 year, with most aller ies identi ied by the a e o
can be severe and li e threatening. T is patient will require
2 years. Cow’s milk and e aller ies tend to resolve by
the premedication or this elective procedure. T e appropri-
ad lthood. The 2013 ideline rom American Academy
ate premedication regimen or contrast dye allergy includes
o Aller y, Asthma and Imm nolo y recommended in-
(1) diphenhydramine 50 mg IM/PO 1 hour be ore the pro-
trod ction o hi hly aller enic ood as early as 4 months
cedure and (2) prednisone 50 mg PO 13 hours, 7 hours, and
o a e, which has shown to red ce ood aller y later.
1 hour be ore the procedure. “A” is incorrect. T e use o lower-
osmolality radiocontrast media is associated with ewer adverse
reactions and is appropriate or contrast-allergic patients. “B”
is incorrect. est dosing or radiocontrast media should not wo months later, this patient required an emergency room
be done; patients with no reaction to test doses have had severe visit af er developing increased work o breathing, wheezing,
reactions to ull doses. In addition, test doses themselves have and an urticarial rash af er eating. You re er him or testing.
been reported to result in atalities. Skin testing (“D”) can He is tested by both percutaneous skin testing and RAS and
be done, especially within a window o a ew months a er the is ound to have egg allergy.
reaction. In the past, skin testing was not recommended, but its
role is evolving, and may become available in the near uture. Question 4.2.2 Which o the ollowing vaccinations should
T ere is no desensitization procedure available. NOT be given to this patient in light o his egg allergy?
A) MMR vaccine.
B) Inactivated polio vaccine.
HELPFUL TIP: C) Haemophilus inf uenzae B vaccine.
There is no cross-reaction between shellfish and D) Conjugated pneumococcal vaccine (Prevnar).
iodine-based contrast material. The aller y to sea- E) raditional in uenza vaccine.
ood is an aller y to the protein (tropomyosins) in the
sea ood, not the iodine. Think abo t it or a second. Answer 4.2.2 The correct answer is “E.” raditional in uenza
How many people have yo seen droppin dead rom vaccine should not be given to individuals with egg allergy. O
an anaphylactic reaction to iodized salt? particular note is “A.” “A” is incorrect. It had been common prac-
tice to withhold measles vaccination rom children with a his-
tory o anaphylactic reaction to egg; the measles vaccine is pre-
pared in chick-embryo broblast cultures. However, the MMR
is sa e to use in children with an egg allergy. Options “B,” “C,”
CASE 4.2 and “D” do not contain egg-related products and can there ore
An 18-month-old boy comes to clinic with a history o eczem- be given sa ely to this patient.
atous rash covering his extremities and ace. His parents state
that it worsens af er the ingestion o certain oods. He has HELPFUL TIP:
had increased ussiness over the last several months, as well There are two preparations o e - ree in l enza
as some di culty gaining weight. Food allergy is suspected. vaccine licensed in the u nited States. These are