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Questions 09/13/2012

Thoracic Musculoskeletal

Question 1
A 37-year-old woman complains of chills, weakness, pleuritic
chest pain, and a nonproductive cough for 5 days. She
reports stopping her highly active antiretroviral therapy
(HAART) medications 2 months ago due to the side effects.
Her chest x-ray shows patchy, perihilar infiltrates. Her
arterial blood gas shows a PaO2 of 68 mm Hg. In addition to
antibiotics you should give her:
a) Ibuprofen 800 mg three times a day
b) Dapsone 100 mg orally daily
c) Prednisone 40 mg orally twice daily
d) Trimethoprim-sulfamethoxazole 15 mg/kg intravenously
every 6 hours
e) Nebulized albuterol 2.5 mg/3 mL four times a day

Answer 1
Pneumocystis jiroveci (Pneumocystic
carini) pneumonia (PCP)
TMP/SMX primary antibiotic of choice
Dapsone used in patients with sulfa
allergy
Prednisone used in patients with
PaO2 < 70 mm Hg
Given prior to antibiotics

Question 2
A 35-year-old woman who is generally healthy complains of fever
and cough with sputum production. Vital signs: heart rate 115/min;
respiratory rate 24/min; blood pressure 126/88 mm Hg; pulse
oximetry, 97% on room air. You initially hear wheezing, but she
improves with nebulized albuterol. Chest x-ray shows a right lower
lobe infiltrate with effusion. The most appropriate next step is to:
a) Obtain decubitus films and begin intravenous ceftriaxone for
possible empyema
b) Obtain CBC and sputum and blood cultures and begin
intravenous ceftriaxone and intravenous azithromycin
c) Obtain urgent echocardiography to determine ejection fraction
and evidence of pericardial effusion
d) Begin oral azithromycin and discharge home
e) Begin oral penicillin VK and discharge home

Answer 2

Community Acquired Pneumonia


Oral macrolide drug of choice
Scoring systems include Pneumonia Severity Index or CURB-65
Pneumonia Severity Index
Low risk class (age < 50, no significant comorbid conditions [neoplasm,
CHF, cerebrovascular disease, renal disease, liver disease, HIV],
lacking: altered mental status, pulse > 125, respiratory rate > 30,
systolic blood pressure < 90 mm Hg, temperature < 35 C or > 40 C)

CURB-65
Confusion
Uremia (BUN > 20 mg/dL)
Respiratory rate > 30
Blood pressure < 90 systolic or greater than 60 diastolic
Age > 65

Question 3
A 75-year-old woman with rheumatoid arthritis
complains of fever and a swollen left knee.
You aspirate her knee and find cloudy fluid; the
Gram stain is positive for Gram-positive cocci.
The drug of choice to treat her is:
a) Clindamycin
b) Trimethoprim-sulfamethoxazole
c) Ciprofloxacin
d) Vancomycin
e) Azithromycin

Answer 3
Septic joint
Patients with inflammatory joint
disease at increased risk
Staph aureus most common cause in
patients with rheumatoid arthritis

Question 4
Which of the following muscles is the
most commonly injured in rotator cuff
tears?
a) Supraspinatus
b) Infraspinatus
c) Subscapularis
d) Teres minor
e) Deltoid

Answer 4
Rotator cuff tears
Rotator cuff muscles - supraspinatus,
infraspinatus, teres minor,
subscapularis (SITS)
Drop arm test passive abduction of
patients shoulder with slow lowering
of arm to waist. Positive when patient
is unable to lower arm smoothly to
waist.

Question 5
A 34-year-old man presents with chest pain and shortness of
breath after being struck in the right side of the chest with a
baseball bat. Chest x-ray demonstrates a 30% pneumothorax
on the right. Which of the following is the most appropriate
management at this time?
a) Needle thoracostomy at the second intercostal space,
midclavicular line
b) Needle thoracostomy at the fifth intercostal space,
midclavicular line
c) Tube thoracostomy at the second intercostal space,
midaxillary line
d) Tube thoracostomy at the fifth intercostal space, midaxillary
line
e) Observation alone

Answer 5
Pneumothorax
Indications for tube thoracostomy
Traumatic cause of pneumothorax (except asymptomatic, apical
pneumothorax)
Moderate to large pneumothorax (>15-20%)
Respiratory symptoms regardless of size of pneumothorax
Increasing size of pneumothorax after initial conservative therapy
Recurrence of pneumothorax after removal of the initial chest
tube
Patient requires ventilator support
Patient requires general anesthesia
Associated hemothorax
Bilateral pneumothorax regardless of size
Tension pneumothorax

Question 6
What is the most common finding in
cauda equina syndrome?
a) Urinary retention
b) Decreased anal sphincter tone
c) Weakness or numbness in the lower
extremities
d) Saddle anesthesia

Answer 6

Cauda equina
Urinary retention most common finding
Sensitivity of 90%
Specificity 95%
Unlikely if post void residual volume less
than 100 to 200 mL
Saddle anesthesia sensitivity 75%
Decreased sphincter tone found in 6080% of cases

Question 7
In what region are the majority of
metastatic epidural cord compressions
found?
a) Cervical spine
b) Thoracic spine
c) Lumbar spine
d) Sacral nerve roots

Answer 7

Metastatic epidural cord compression


68% occur in the thoracic spine
15% occur in the cervical spine
19% occur in the lumbosacral spine
Back pain is the initial presentation in
95% of patients with epidural
metastasis

Question 8
A 67-year-old building contractor is brought to the ED by his wife. She
says that he has become very confused and is suffering from watery
diarrhea and a dry cough. The patient appears acutely ill, tachypneic,
diaphoretic, and confused. His temperature is elevate at 38.9 C (102 F).
You hear scattered, dry rales, but the remainder of the examination is
unremarkable. WBC is 23,000/mm3 with a left shift; chest x-ray shows a
patchy left upper lobe air-space infiltrate. Which of the following
statements concerning the most likely cause of his illness is correct?
a) Transmission is generally person-to-person
b) The usual incubation period is in the range of weeks rather than days
c) Other complications include skin sloughing and mucosal ulcerations
d) Travel and work histories are important considerations when
diagnosing this illness
e) Early empiric antibiotic therapy with intravenous Trimethoprim every
12 hours is necessary to reduce mortality, which is as high as 40% if
the disease is untreated

Answer 8
Legionella
Atypical pneumonia
Associated w/ gastrointestinal
symptoms such as diarrhea and
abdominal cramping
Mortality in up to 30% of cases
Definitive diagnosis made by
isolation from respiratory secretions

Question 9
Which of the following medications is
FDA-approved for the treatment of
hiccups?
a) Droperidol
b) Chlorpromazine
c) Metoclopramide
d) Nifedipine

Answer 9
Chlorpromazine
Only FDA approved drug for hiccups
Start at 25 mg PO TID

Question 10
An otherwise healthy nurse who is employed in a
suburban community clinic presents to your ED
fast-track area because of concerns about a
possible positive PPD test placed 48 hours ago after
routine health care testing. She has had no known
tuberculosis exposure. Which of the following
criteria apply to confirm a positive PPD test?
a) Induration > 5 mm
b) Induration > 7.5 mm
c) Induration > 10 mm
d) Induration > 15 mm

Answer 10
PPD
> 5 mm
HIV-infected persons
Close contacts of persons with infectious
tuberculosis
Persons with abnormalities on chest radiograph
consistent with previous tuberculosis
Immunosuppressed patients receiving the
equivalent of > 15 mg of prednisone per day
for > 1 month

Answer 10
> 10 mm
Foreign-born persons recently arrive (<5 years earlier) from a country with a
high prevalence of tuberculosis
Persons with a medical condition that increases risk of tuberculosis (silicosis,
ESRD, malnutrition, diabetes, carcinoma of the head/neck/lung,
immunosuppressive therapy, lymphoma, leukemia, loss of more than 10% of
ideal body weight, gastrectomy, jejunoileal bypass)
Injection drug users
Members of medically underserved, low-income populations (e.g homeless)
Resident and staff members of long-term care facilities (e.g. nursing homes,
correctional facilities, homeless shelters)
Health care workers
Children < 4 years of age
Persons with conversion on a tuberculin skin test (increase in induration of >
10 mm within a 2 year period)

> 15 mm
All others