Questions, Board Review

Board Review Questions: June 2020

PEER (Physician’s Evaluation and Educational Review in Emergency Medicine) is ACEP’s gold standard in self-assessment and educational review. These questions are from PEER, updated continually on its digital platform. Order PEER to prepare!

1. Which behavior is most associated with drug seeking and frequent use of the emergency department?
A. Asking for pain relief early in the visit
B. Having a disease associated with chronic pain
C. Lacking primary care follow-up
D. Rating pain greater than 10 on a 10-point scale


2. An 84-year-old woman presents following an episode of dyspnea and near syncope. A systolic crescendo-decrescendo murmur is noted on examination. Which pharmacotherapy should be avoided?
A. Digitalis
B. Lisinopril
C. Nitroglycerin
D. Statins


3. Which condition is the most likely cause of widened mediastinum in a patient who has been experiencing weight loss and fatigue for several weeks?
A. Boerhaave syndrome
B. Chest lymphoma
C. Descending necrotizing mediastinitis
D. Inhalation anthrax


4. A 20-year-old man is brought in by his friends because he took LSD and is having a "bad trip." On examination, he is warm, tachycardic, and flushed. He is paranoid, agitated, and physically combative. Which treatment is indicated?
A. Activated charcoal
B. Intravenous bicarbonate
C. Intravenous diazepam
D. Intravenous naloxone


5. A 30-year-old man presents with new-onset unilateral hearing loss after being close to an explosion. His vital signs are normal, and he is otherwise asymptomatic. A thorough physical examination is normal except for the presence of a perforated tympanic membrane. What is the most appropriate initial radiographic evaluation?
A. Abdominal CT
B. Abdominal ultrasound
C. Brain CT
D. Chest x-ray

ANSWERS 

1. The correct answer is D, Rating pain greater than 10 on a 10-point scale.
Why is this the correct answer?
Drug-seeking behavior, a form of malingering, is a common concern for emergency physicians. Certain behaviors tend to be associated with patients who are misusing or abusing prescription opioid medications; in a case-control study of 152 patients enrolled in a case-management program for prescription abuse, the factor most associated with abuse was reporting pain levels greater than 10 out of 10. Requesting parenteral medications, claiming to be out of medications, and having at least three visits in 7 days were also associated with prescription abuse. In a different retrospective analysis, other indicators of drug-seeking behaviors included patients requesting a specific medication by name, making multiple visits for the same complaint, and having a "suspicious history." According to one source, prescription drug abuse increased 400% from 1999 to 2010. Although estimates of prevalence vary widely, patients demonstrating drug-seeking behavior represent a minority of emergency department visits. It is important to recognize that patients with chronic pain who are undertreated may also demonstrate some of these behaviors; this trend is called “pseudoaddiction” and tends to resolve once the pain is adequately treated.

Why are the other choices wrong?

  • Patients in pain should be expected to ask for pain relief, and it is the duty of emergency physicians to provide prompt, effective pain relief for patients with acutely painful conditions. Asking for a specific medication may seem suspicious, but seeking pain control is generally why these patients choose the emergency department for their care.
  • Patients with chronically painful conditions, such as sickle-cell disease, often struggle with frequent episodes of severe pain, and inadequately treated pain can lead to pseudoaddiction and the demonstration of drug-seeking behaviors. An appropriate case-management plan for these high-utilizing patients can help to provide more consistency and continuity in care.
  • Many emergency department patients lack access to primary care follow-up, but that alone has not been identified as a high-risk indicator of patients inappropriately seeking narcotic medications. Socioeconomic challenges are not a reason to deny appropriate use of opioid analgesia for acutely painful conditions.

REFERENCES
Grover CA, Close RJH, Wiele ED, Villarreal K, Goldman LM. Quantifying drug-seeking behavior: a case control study. J Emerg Med. 2012 Jan;42(1):15-21.

Miner JR, Burton JH. Pain management. In: Walls RM, Hockberger RS, Gausche-Hill M, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. Vol 1. 9th ed. Philadelphia, PA: Elsevier; 2018:34-52.

Cline DM. Chronic pain. In: Tintinalli JE, Ma OJ, Yealy DM, et al, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9th ed. New York, NY: McGraw-Hill; 2020:259-266.

2. The correct answer is C, Nitroglycerin.
Why is this the correct answer?
Aortic stenosis (AS) is the third most common form of cardiovascular disease in developed countries after hypertension and coronary artery disease. Significant care should be taken when treating AS patients with preload-reducing agents (nitrates) because the sudden decrease in preload can cause severe hypotension, which can lead to decreased coronary flow and worsened ischemia and shock. Diuretics and inotropic agents can also be deleterious and should be used with caution. Managing AS is challenging; judicious use of fluids, maintenance of normal sinus rhythm, and avoidance of nitrates are recommended.

The most common causes of AS are calcification of a normal trileaflet aortic valve and a congenital bicuspid aortic valve. AS usually progresses slowly, with symptoms taking decades to manifest in most cases. Auscultation reveals a systolic crescendo-decrescendo murmur associated with diminished and delayed carotid pulses (parvus et tardus), a sustained left ventricular impulse on palpation, and a decreased or absent aortic component of the second heart sound. An ECG can show left ventricular hypertrophy with a repolarization abnormality, which is seen in 85% of patients with severe AS. Yearly echocardiography is indicated for patients with severe AS to assess condition severity, wall thickness, and left ventricle function. Exercise stress testing can lead to complications in patients with symptomatic AS and should not be performed. Once symptoms appear, the average survival time in AS is 2 to 3 years, with a risk for sudden death (<1% per year). Syncope develops in 15% of AS patients, angina in 35%, and congestive heart failure in 50%.

Why are the other choices wrong?

  • According to guidelines from the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery, digitalis is recommended for use in AS patients who are not candidates for surgery. Unlike beta-blockers and calcium channel blockers, digitalis can be used to control the heart rate of AS patients because it is unlikely to cause hypotension.
  • Lisinopril and other ACE inhibitors can be used to treat hypertension in patients with aortic valve disease. However, care should be taken with dosing to avoid hypotension.
  • No medical treatment has been shown to decrease disease progression in the aortic valve leaflets. Although statins are currently being studied, they have not been shown to worsen symptoms of AS. Statins are used in patients with AS and atherosclerotic heart disease.

REFERENCES
Borczuk P. Cardiac valvular disorders. In: Adams JG, Barton ED, Collings J, DeBlieux PMC, Gisondi MA, Nadel ES, eds. Emergency Medicine: Clinical Essentials. 2nd ed. Philadelphia, PA: Elsevier Saunders; 2013:524-529.

Kosowsky JM, Takhar SS. Infective endocarditis and valvular heart disease. In: Marx JA, Hockberger RS, Walls RM, et al, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. Vol 1. 8th ed. Philadelphia, PA: Elsevier Saunders; 2014:1106-1112.

Vahanian A, Alfieri O, Andreotti F, et al; The Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Guidelines on the management of valvular heart disease (version 2012). Eur Heart J. 2012 Oct;33(19):2451-2496.

3. The correct answer is B, Chest lymphoma.
Why is this the correct answer?
If a posterior-anterior standing chest x-ray has been taken with good inspiration and no rotation, then any widening of the mediastinum is likely to be genuine; thus, the main pathological causes to consider include masses and widening of vessels. Of the choices listed, chest lymphoma is the most common cause of widened mediastinum, making the diagnosis particularly likely in a patient who reports weight loss and fatigue. The mediastinum is composed of anterior, middle, and posterior compartments. The anterior causes of a widened mediastinum include the “four T’s:” (terrible) lymphoma, thymoma, teratoma/germ-cell tumor, and thyroid tissue. The middle causes of widened mediastinum, in order of decreasing occurrence, are lymphadenopathy secondary to lymphoma, sarcoid, and metastatic lung cancer. Neurogenic tumors are the most common posterior causes of widened mediastinum.

Why are the other choices wrong?

  • Pneumomediastinum is a potential complication of Boerhaave syndrome and tracheobronchial injury that results in a widened mediastinum in 20% of patients. It can cause a crackling sound (known as the “Hamman crunch”) that is typically heard on chest auscultation coincident with each heartbeat and can be mistaken for a pericardial friction rub. Esophageal rupture in Boerhaave syndrome likely results from a sudden rise in intraluminal esophageal pressure produced during vomiting due to neuromuscular incoordination, which causes the cricopharyngeus muscle to fail to relax. Although these conditions can be associated with a widened mediastinum, they are uncommon and do not typically present with the same symptoms as lymphoma.
  • Descending necrotizing mediastinitis is a rare and potentially fatal cause of widened mediastinum. It is caused by the spreading of a head or neck infection to the mediastinum from tonsillitis, dental abscess, or sinusitis. These infections are often polymicrobial and produce gas, which contributes to the widening of the mediastinum.
  • Although inhalation anthrax can cause a widened mediastinum, it is incredibly rare. Anthrax results in a prodromal viral respiratory illness that lasts about 1 week. This stage is followed by acute hypoxia, dyspnea, or acute respiratory distress with resulting cyanosis. In some patients, mediastinal widening and hilar adenopathy are seen on x-ray, but patients generally do not complain of weight loss.

REFERENCES
Brown JE. Chest pain. In: Marx JA, Hockberger RS, Walls RM, et al, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. Vol 1. 8th ed. Philadelphia, PA: Elsevier Saunders; 2014:214-222.

Schultz CH, Koenig KL. Weapons of mass destruction. In: Marx JA, Hockberger RS, Walls RM, et al, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. Vol 2. 8th ed. Philadelphia, PA: Elsevier Saunders; 2014:2472-2474.

MacIntyre AG, Barbera JA. Bioterrorism. In: Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline DM, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill Education; 2016:46-51.

Mendelson M. Esophageal emergencies. In: Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline DM, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill Education; 2016:508-514.

Mickley ME, Gutierrez C, Carney M. Oncologic and hematologic emergencies in children. In: Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline DM, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill Education; 2016:967.

4. The correct answer is C, Intravenous diazepam.
Why is this the correct answer?
The patient in this case is showing signs of delirium associated with LSD intoxication. Oral or intravenous benzodiazepines, such as lorazepam or diazepam, can be helpful in hallucinogen toxicity for the management of agitation and delirium. Additionally, benzodiazepines alone are often sufficient to control the associated hypertension and tachycardia. They also are the first-line therapy for the treatment of hallucinogen-induced seizures. The effects of LSD begin to manifest about 30 minutes after ingestion; they peak at 4 hours and generally last 8 to 12 hours. Patients can present with sympathomimetic stimulation, including tachycardia, hyperthermia, and hypertension, and they may also have facial flushing, piloerection, increased muscle tension, and hyperreflexia. Large overdoses can result in seizures, coma, coagulopathy, and respiratory failure. “Bad trips,” or dysphoric reactions, are more common with LSD than with other hallucinogens, such as Psilocybe cubensis mushrooms.

Why are the other choices wrong?

  • Gastric decontamination is rarely indicated after hallucinogen ingestion. Most substances in this class are rapidly absorbed, and patients typically do not present until several hours after ingestion. Although the patient in this case is showing signs of LSD intoxication, activated charcoal is of little benefit. Activated charcoal can be considered if the hallucinogen was ingested within the last hour or in cases of delayed gastric emptying, such as with anticholinergic poisoning.
  • Intravenous bicarbonate can treat the ingestion of substances that cause similar symptoms (including dysrhythmias) by changing the pH to counteract cardiac conduction disorders. With LSD intoxication, this mechanism is not a useful treatment.
  • Naloxone, a competitive opioid antagonist, is used in the management of opioid overdoses to reduce respiratory depression. This patient is not exhibiting symptoms of opioid overdose, and there is no indication for naloxone in LSD intoxication.

REFERENCES
Ly BT, Williams SR. Hallucinogens. In: Marx JA, Hockberger RS, Walls RM, et al, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. Vol 2. 8th ed. Philadelphia, PA: Elsevier Saunders; 2014:2015-2023.

Prybys KM, Hansen KN. Hallucinogens. In: Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline DM, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill Education; 2016:1260-1265.

5. The correct answer is D, Chest x-ray.
Why is this the correct answer?
This patient has a tympanic membrane perforation, the most common complication from a primary blast injury. Performing a chest x-ray is appropriate for all blast injury patients with pulmonary complaints or signs of a primary blast injury, including tympanic membrane rupture — even in the absence of pulmonary symptoms. An observation period is important, even if the chest x-ray is normal, because primary blast injuries can have delayed manifestations. Primary blast injuries result from transmitted overpressure on the body, and they occur most frequently at air-tissue interfaces. High air-content organ systems are most at risk. In descending order of frequency, the most commonly injured organs are the tympanic membrane, lung, and bowel. Given the tympanic membrane’s sensitivity to transmitted overpressure, patients exposed to a blast should be evaluated for perforation, and the presence of tympanic membrane rupture should heighten suspicion for other injuries. Asymptomatic patients with intact tympanic membranes rarely develop other primary blast injuries, but the absence of tympanic membrane rupture alone does not exclude the possibility that other primary blast injuries will develop.

Why are the other choices wrong?

  • Emergency physicians should maintain a low threshold for evaluating patients radiographically after a blast injury. However, evidence of tympanic membrane rupture alone is not an indication to obtain a CT scan of the abdomen. The bowel is the third most common hollow organ to be injured in a blast injury (following the tympanic membrane and lung). Nevertheless, observation and serial examinations for asymptomatic patients are appropriate prior to discharge.
  • Tympanic membrane rupture alone is also not an indication to perform an abdominal ultrasound. Ultrasound is not sensitive for the evaluation of bowel injuries, which are the most common abdominal injuries after a primary blast injury. A chest x-ray is much more likely to be of greater yield.
  • Similarly, tympanic membrane rupture alone is not an indication to perform a brain CT scan after a blast injury. Serial examinations in asymptomatic patients are appropriate prior to discharge.

REFERENCES
Bono MJ, Halpern PP. Bomb, blast, and crush injuries. In: Tintinalli JE, Ma OJ, Yealy DM, et al, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9th ed. New York, NY: McGraw-Hill; 2020:30-35.

Callaway DW, Sanchez LD. Blast injuries. In: Wolfson AB, Cloutier RL, Hendey GW, Ling LJ, Rosen CL, Schaider JJ, eds. Harwood-Nuss’ Clinical Practice of Emergency Medicine. 6th ed. Philadelphia, PA: Wolters Kluwer; 2015:316-317.

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