Questions, Board Review

Board Review Questions: October 2023

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1. A 35-year-old man presents with sudden, severe, tearing pain with bowel movements. He says he has a burning sensation between bowel movements. He has not noticed any swelling but says he once “saw blood on the toilet paper afterward.” The physical examination is limited by intense pain on performance of digital rectal examination. What is the best initial treatment for this patient’s condition?

A. Botulinum toxin injection
B. Elliptical incision
C. Sitz baths and a high-fiber diet
D. Topical nitroglycerin

The correct answer is C, Sitz baths and a high-fiber diet.

Why is this the correct answer?
Anal fissures are the most common cause of acute-onset severe rectal pain. Treatment for anal fissures includes sitz baths and a high-fiber diet. Anal fissures can be caused by a tear in the anoderm from the passage of hard feces, usually in patients who are constipated. Patients often report seeing bright red blood on the toilet paper or in the stool. Most fissures are located at the posterior midline, where muscle fibers that surround the anus are the weakest. Fissures that are located outside the midline are associated with systemic disease, such as HIV, tuberculosis, or Crohn disease. Anal fissures that are not treated in a timely manner can become chronic with a triad of deep ulceration, sentinel pile (edematous and hypertrophic skin), and enlarged anal papillae.

Why are the other choices wrong?

  • A botulinum toxin injection can reduce sphincter pressure, providing some relief from the local spasm and severe pain caused by a fissure. Complications include stool incontinence, which is generally temporary. However, botulinum toxin injection is not the recommended initial treatment for an acute rectal fissure in the emergency department.
  • An elliptical incision is used to open and excise the clot from a thrombosed hemorrhoid, but it is not the best treatment for anal fissure in the emergency department. If the symptoms of an anal fissure do not improve in 1 to 2 months, then a specialist may use an elliptical incision in the surgical excision of the fissure. Sphincterotomy is the most successful treatment for chronic fissures but is not the initial treatment.
  • Topical nitroglycerin can also be used to decrease the severe pain caused by the anal spasm associated with a fissure. Side effects of topical nitroglycerin include headaches and flushing, so it is not the first-line treatment.

Nelson RL, Thomas K, Morgan J, Jones A; Cochrane Colorectal Cancer Group. Non surgical therapy for anal fissure. Cochrane Database Syst Rev. 2012 Feb 15;2012(2):CD003431.

Reichman EF. Anal fissure management. In: Reichman EF, ed. Reichman's Emergency Medicine Procedures. 3nd ed. McGraw-Hill Education; 2019:738-744.

Coates WC. Anorectum. In: Walls RM, Hockberger RS, Gausche-Hill M, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. Vol 1. 10th ed. Elsevier; 2023:1151-1162.

Berberian JG, Burgess BE. Anorectal disorders. Tintinalli JE, Stapczynski JS, Ma OJ, et al, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 9th ed. McGraw-Hill Education; 2020:536-551.

2. Which life-threatening skin disorder has mucocutaneous involvement, a positive Nikolsky sign, and full-thickness skin sloughing involving approximately 8% of total body surface area?

A. Erythema multiforme
B. Staphylococcal scalded skin syndrome
C. Stevens-Johnson syndrome
D. Toxic epidermal necrolysis

The correct answer is C, Stevens-Johnson syndrome.

Why is this the correct answer?
Stevens-Johnson syndrome (SJS) is a life-threatening dermatologic condition described as a diffuse rash with target lesions that progress to blisters and bullae. SJS involves the hands, soles, and mucous membranes with full-thickness skin necrosis affecting less than 10% of the total body surface area (BSA). SJS is often caused by a drug reaction, although infection and malignancy have also been implicated. SJS was once described as part of a continuum of dermatologic conditions starting with erythema multiforme (EM), progressing to SJS, and culminating in toxic epidermal necrolysis (TEN). However, EM is now believed to be distinct from SJS and TEN.

SJS is defined as skin detachment of <10% BSA, whereas TEN is more severe, defined as >30% BSA skin detachment. Another entity, SJS/TEN overlap, is defined as skin detachment of 10% to 30% BSA. Treatment for SJS requires hospitalization in an ICU or burn unit for optimal administration of fluids and electrolytes, control of pain and infection, and cessation of the offending agent.

Why are the other choices wrong?

  • Erythema multiforme (EM) is a discrete rash known best for its target lesion appearance. It is associated with several culprits: infections (HSV), drugs (sulfa and other antibiotics, anticonvulsants), autoimmune diseases, and idiopathic etiologies. There are two classifications of EM: minor and major. EM minor is a self-limited rash that mostly involves the extremities and has no prodromal symptoms or mucous membrane involvement. Outpatient treatment and supportive care are usually adequate. EM major is more severe, starting with a prodromal viral illness and progressing to a rash that involves the palms, soles, and mucous membranes. Treatment typically includes observation to ensure the disease does not progress further.
  • Staphylococcal scalded skin syndrome (SSSS), also known as Ritter disease or dermatitis exfoliativa neonatorum, is a diffuse, tender, scarlatiniform erythematous rash. It causes skin blisters and sloughing (positive Nikolsky sign), but the mucous membranes are spared. It is most often seen in infants and has a low mortality rate of less than 5%. Although SSSS is rare in adults, it has a much higher mortality rate when it does occur in adults. An exfoliative toxin in certain strains of Staphylococcus aureus causes SSSS. Both SSSS and bullous impetigo are blistering skin diseases caused by the staphylococcal exfoliative toxin. In bullous impetigo, the exfoliative toxins are restricted to the area of infection, and bacteria can be cultured from the blister contents. In SSSS, the exfoliative toxins spread hematogenously, causing epidermal damage at distant sites; the bullous materials are sterile. Treatment consists of supportive care (fluids and pain control) and eradication of the primary infection.
  • Toxic epidermal necrolysis (TEN), also known as Lyell disease, is a life-threatening dermatologic condition characterized by a diffuse, erythematous macular rash that coalesces to form bullae; necrosis develops, and the epidermis separates from the dermis. SJS and TEN are thought to be part of a spectrum of disease. SJS is the less severe form, with <10% BSA of skin detachment; TEN is more severe, with >30% BSA skin detachment. SJS/TEN overlap encompasses 10% to 30% BSA of skin detachment. Mucosal involvement and positive Nikolsky sign are both present. In TEN, symptoms first affect the eyes, then spread caudally to the thorax and upper extremities, and finally progress to the lower body, involving more than 30% of BSA. TEN is most commonly drug-induced (sulfa, penicillin, and NSAIDs are implicated) but has also been associated with infection, malignancy, and vaccines. People with AIDS who are taking sulfa prophylaxis have a thousand-fold higher risk of developing TEN. Patients with TEN are treated in an ICU or burn unit. Administration of the offending agent is stopped, and fluids, electrolytes, and pain and infection control are provided. To date, no specific therapy has proven effective. Despite hospitalization and aggressive resuscitation, the mortality rate in patients with TEN remains high secondary to sepsis and multisystem organ failure.

Murphy-Lavoie H, LeGros TL. Approach to the adult rash. In: Adams JG, Barton ED, Collings JC, DeBlieux PMC, Gisondi MA, Nadel ES, eds. Emergency Medicine Clinical Essentials. 2nd ed. Elsevier Saunders; 2013:1598-1610.

Marco CA. Dermatologic presentations. In: Walls RM, Hockberger RS, Gausche-Hill M, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. Vol 2. 10th ed. Elsevier; 2023:1428-1451.

DermNet NZ article on Stevens-Johnson syndrome/toxic epidermal necrolysis

DermNet NZ article on erythema multiforme

DermNet NZ article on staphylococcal scalded skin syndrome

UpToDate article on Stevens-Johnson syndrome and toxic epidermal necrolysis, available in full with a subscription

3. A 56-year-old woman presents with severe pain in the index finger of her right hand. She says that she punctured it 2 days ago while gardening. On examination, the finger is swollen and tender. Sensation and circulation are intact, but the patient is unable to extend the finger without screaming in pain. What is the best next step?

A. Discharge with antibiotics and follow-up instructions
B. Immobilize the finger for comfort
C. Perform incision and drainage
D. Start parenteral antibiotics

The correct answer is D, Start parenteral antibiotics.

Why is this the correct answer?
Flexor tenosynovitis is an infection of the tendon sheath that risks progression to the deep spaces of the hand and subsequent necrosis and proximal spread. Parenteral antibiotics must be started immediately to minimize the risk of deep space infection. Additionally, a hand surgeon should be consulted in all cases of suspected flexor tenosynovitis. This patient is exhibiting the classic Kanavel signs that support a clinical diagnosis, which include tenderness to palpation over the flexor tendon sheath, symmetric finger swelling, pain with passive extension, and flexed positioning of the digit to minimize pain.  If flexor tenosynovitis is identified and treated early, it can sometimes be treated successfully without surgery.

Patients with flexor tenosynovitis frequently have a puncture wound as the inciting event; however, many have no identifiable cause. The most common bacteria are Staphylococcus and Streptococcus, but sexually active patients without an identifiable source of infection should also be treated for presumed disseminated gonorrhea.

Why are the other choices wrong?

  • Because of the high risk of deep space infections of the hand, discharge with oral antibiotics and instructions to see a hand surgeon is inappropriate in a case of presumed flexor tenosynovitis. Parenteral antibiotics should be started immediately, and consultation with a hand surgeon should be initiated in the emergency department. Nonsurgical treatment can sometimes be considered, but this decision must be made in collaboration with the hand surgeon and with follow-up within 24 hours.
  • Immobilizing the finger for comfort is not the priority in a patient with flexor tenosynovitis. This presentation is an infectious emergency of the hand that must be treated, preferably with parenteral antibiotics and consultation with a hand surgeon. A bulky dressing can be placed with elevation of the affected part in early cases, but it does not take priority over antibiotics.
  • Hand infections involving subcutaneous tissue are routinely managed by emergency physicians with incision and drainage. However, incision and drainage is the wrong approach to treating flexor tenosynovitis in the emergency department. The flexor sheath where the infection is located is much deeper than the typical abscesses emergency physicians routinely treat with incision and drainage; the sheath is also in very close proximity to the tendon. The treatment for this surgical emergency is appropriately managed by a hand surgeon.

Schoener B, Wagner MJ. Hand injuries. In: Walls RM, Hockberger RS, Gausche-Hill M, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. Vol 1. 10th ed. Elsevier; 2023:458-499.

Germann CA. Nontraumatic disorders of the hand. In: Tintinalli JE, Ma OJ, Yealy DM, et al, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9th ed. McGraw-Hill Education; 2020:1914-1920.

USA Health video about flexor tenosynovitis and the Kanavel signs

4. A 26-year-old man presents via ambulance and is surrounded by police officers. He shouts verbal threats at staff members while being taken into a treatment room. His girlfriend says he has bipolar disorder and has been behaving erratically. Which technique for managing this patient's aggressive behavior should be attempted first?

A. Physical restraint
B. Sedation
C. Show of force
D. Verbal de-escalation

The correct answer is D, Verbal de-escalation.

Why is this the correct answer?
Regardless of which technique is used to diffuse a potentially violent patient encounter or subdue an aggressive patient, the first objective is to ensure the safety of the patient, staff, and other persons nearby. Recommended approaches are typically stepwise, starting with verbal de-escalation, followed by a show of force, pharmacologic management, and physical restraint.

In one study of verbal de-escalation of agitated patients, researchers suggest a three-step approach: engage the patient verbally, establish a collaborative relationship, and de-escalate the patient's agitated or aggressive state verbally. The study’s authors suggest that the initial attempt to engage the patient is a verbal loop: the physician listens to the patient, circles back to a statement they can validate or agree with, and then tells the patient what they or the staff want to happen next. The word “loop” is used because this initial conversation might require many repetitions, but if it is effective, other measures such as chemical and physical restraints might be avoided. Attitude and body language are key factors in the success of verbal de-escalation attempts; other considerations include respecting personal space, avoiding provocation, being concise, setting clear limits, offering choices and optimism, and listening closely to what the patient says.

Why are the other choices wrong?

  • Physical restraint may become necessary in the management of an agitated or aggressive patient after verbal and pharmacologic strategies fail. The patient should be restrained in the supine position or on one side. The head of the bed should be slightly elevated to prevent aspiration. A restrained patient should be monitored frequently to prevent injury, and clinical efforts should focus on removing the restraints as soon as safely possible. It is never appropriate to restrain a patient in a prone position. The technique of securing a proned patient's legs to their hands, known as a hog-tie, is linked to positional asphyxia and death.
  • Many classes of medication are available for sedation. Typical antipsychotics (eg, haloperidol) and atypical antipsychotics (eg, olanzapine) are used frequently. Physicians should keep in mind that these medications have many potential adverse effects, including QT-interval prolongation and increased risk of death in elderly persons. Benzodiazepines, including lorazepam, are another popular and effective choice for pharmacologic restraint. These medications should be considered if verbal de-escalation and a show of force fail.
  • A show of force involves surrounding the patient with numerous security and emergency department personnel to demonstrate that combative behavior is not tolerated. This strategy is considered the patient's last chance to calm down before more aggressive techniques, such as sedation and physical restraint, are used. A show of force is an appropriate next step if verbal de-escalation fails.

Tucci V, Moukaddam N. Mental health disorders: ED evaluation and disposition. In: Tintinalli JE, Ma OJ, Yealy DM, et al, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9th ed. McGraw-Hill Education; 2020:1933-1937.

Horn AE, Dubin WR, Zun LS. Management of aggressive and violent behavior in the emergency department. In: Zun L, Chepenik LG, Mallory MNS, eds. Behavioral Emergencies for the Emergency Physician. Cambridge University Press; 2013:170-176.

Richmond JS, Berlin JS, Fishkind AB, et al. Verbal de-escalation of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg Med. 2012 Feb;13(1):17-25.

5. A 16-year-old boy presents with eye pain and worsening vision after being struck in the face with a bat during a baseball game. The eyeball is protruding and bloody; intraocular pressure is 45 mm Hg. The ophthalmologist is in surgery and will be unavailable for 1 hour. What is the best next step in management?

A. Arrange for outpatient follow-up
B. Instill pilocarpine and timolol drops
C. Perform lateral canthotomy
D. Perform ocular massage

The correct answer is C, Perform lateral canthotomy.

Why is this the correct answer?
This patient’s presentation is classic for retrobulbar hemorrhage (ie, a history of blunt trauma to the eye followed by symptoms of worsening vision, proptosis, and increased intraocular pressure). Retrobulbar hemorrhage is an ocular emergency, and an ophthalmologist should be consulted immediately. If the ophthalmologist is unavailable and the patient has intraocular pressure greater than 40 mm Hg, then the emergency physician should perform a lateral canthotomy. This procedure decreases the pressure on the blood flow to the optic nerve and can be vision saving. It is also important to consider other causes of a retrobulbar hematoma, such as coagulopathy and thrombocytopenia.

Why are the other choices wrong?

  • Outpatient management is inappropriate in this scenario because retrobulbar hemorrhage is a true ocular emergency requiring immediate intervention. Since the ophthalmologist is unavailable and the patient’s intraocular pressure is greater than 40 mm Hg, the emergency physician should perform a lateral canthotomy.
  • Pilocarpine and timolol drops are used to treat acute angle-closure glaucoma, which can also increase intraocular pressure. Pilocarpine constricts the pupil and opens the trabecular complex, and timolol decreases aqueous humor production. Both medications effectively lower intraocular pressure but have no role in the treatment of increased intraocular pressure from a retrobulbar hematoma. In this case, a lateral canthotomy should be performed.
  • Ocular massage may be considered to treat central retinal artery occlusion (CRAO), which can cause acute vision changes. However, there is no evidence for or against performing this maneuver in CRAO, and the ophthalmologist should be involved if this diagnosis is suspected. Ocular massage has no role in the treatment of retrobulbar hematoma and could worsen an associated open globe injury.

Knoop KJ, Dennis WR. Ophthalmologic procedures. In: Roberts JR, Custalow CB, Thomsen TW, et al, eds. Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care. 7th ed. Elsevier; 2019:1295-1337.

Walker RA, Adhikari S. Eye emergencies. In: Tintinalli JE, Ma OJ, Yealy DM, et al, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9th ed. McGraw-Hill Education; 2020:1523-1560.

Kent TL, Morris CL. Evaluation and management of orbital hemorrhage. EyeNet Magazine. American Academy of Ophthalmology; 2011 Jan.

Ballard SR, Enzenauer RW, O'Donnell T, Fleming JC, Risk G, Waite AN. Emergency lateral canthotomy and cantholysis: a simple procedure to preserve vision from sight threatening orbital hemorrhage. J Spec Oper Med. 2009 Summer;9(3):26-32.

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