Question 1

A 43-year-old man comes to the emergency department with severe abdominal pain and vomiting for the last several days.  He has been drinking wine heavily since separating from his wife recently.  He was admitted to the hospital for alcohol-related seizures a year ago and left against medical advice.  The patient's medical problems also include chronic low back pain and nephrolithiasis.  He takes over-the-counter painkillers.  His temperature is 38.3 C (101 F), blood pressure is 112/70 mm Hg, pulse is 105/min, and respirations are 18/min.  Physical examination is significant for jaundice in the eyes and skin.  Breath sounds are normal.  The abdomen is distended, with significant tenderness in the right upper quadrant to palpation.  There is dullness to percussion in bilateral flank regions.
Laboratory results are as follows:

Which of the following is the most likely diagnosis?

Accepted Answer

11ec193a_9612_4508_853d_e7ef37f2de5d_MD0002_00 This patient's presentation is consistent with alcoholic hepatitis (AH). AH patients typically have a history of excessive alcohol use for >20 years, but they may increase their intake acutely in response to stressful situations. AH typically presents with acute jaundice, fever, anorexia, right upper-quadrant/epigastric pain, and abdominal distention due to ascites. Malnourished patients may also develop muscle wasting with proximal muscle weakness. Laboratory studies usually show elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT) (usually <300 U/L), AST:ALT ratio >2, elevated gamma-glutamyltransferase and international normalized ratio, and low albumin (if malnourished). The serum ferritin is also elevated due to acute inflammation, sometimes >1000 ng/mL. Abdominal imaging may show fatty liver. (Choice A) Acute cholecystitis can present with fever, right upper-quadrant pain, nausea, vomiting, and anorexia. However, jaundice indicates cholangitis and is not typically seen in cholecystitis. (Choice C) For reasons that are unclear, alcoholic liver disease can lead to increased iron in the liver, resembling hemochromatosis. However, hereditary hemochromatosis (HH) has much higher serum iron levels and transferrin saturation is usually >50%. In addition, HH does not have the AST:ALT ratio >2 seen in alcoholic liver disease. (Choice D) Hepatic abscess can present with fever, abdominal pain, anorexia, nausea, vomiting, and elevated liver function tests. However, this patient's extensive use of alcohol and AST:ALT ratio are more suggestive of alcoholic hepatitis. (Choice E) Tylenol toxicity can present with jaundice and abdominal pain. However, it usually causes AST and ALT >500 U/L and does not present with an AST:ALT ratio >2, as seen in this patient. Educational objective: Alcoholic hepatitis (AH) usually presents with acute jaundice, fever, anorexia, right upper-quadrant/epigastric pain, and abdominal distention due to ascites. Patients should have other causes of acute hepatitis excluded. An aspartate aminotransferase:alanine aminotransferase ratio >2 in an alcoholic patient usually distinguishes AH from other causes. __________ References: Review article: the diagnosis and management of alcoholic hepatitis. (http://www.ncbi.nlm.nih.gov/pubmed/19416132) Alcoholic hepatitis. (http://www.ncbi.nlm.nih.gov/pubmed/19553649)

Question 2

A 60-year-old woman comes to the emergency department because of progressive fatigue and low grade fever for the last 2 weeks. She is from Mexico and is currently visiting her children in the United States. She has never been diagnosed with any chronic medical problems. However, she did receive a blood transfusion 20 years ago when she underwent right femur fracture repair after a motor vehicle accident. She denies tobacco, alcohol, or illicit drug use. Her temperature is 37.7 C (99.9 F), blood pressure is 130/76 mm Hg, and pulse is 90/min and regular. Her BMI is 27 kg/m². Physical examination reveals scleral icterus and non-tender rubbery lymph nodes bilaterally in the submandibular, anterior cervical, and axillary areas. Cardiopulmonary examination reveals a 2/6 ejection-type murmur at the left sternal border, and clear lungs. The liver edge is palpated 3 cm below the right costal margin, and the spleen tip is palpated on deep inspiration. There is no skin rash or peripheral edema. Laboratory results are as follows: Which of the following would most likely be present in this patient's peripheral blood smear?

Accepted Answer

11ec193a_9614_67ed_853d_abe87452ec6d_MD0002_00 This patient's presentation is consistent with likely chronic lymphocytic leukemia (CLL), which accounts for nearly 30% of adult leukemias in the United States. Patients typically present with 'B' symptoms (e.g., recurrent fever, night sweats, weight loss, fatigue), anemia, thrombocytopenia, painless lymphadenopathy, and hepatosplenomegaly. Diagnosis is confirmed by peripheral smear showing > 5000/mL mature appearing small B lymphocytes and flow cytometry showing monoclonal B-cell characteristics (e.g., CD19, CD20, CD23). Chronic lymphocytic leukemia is associated with autoimmune hemolytic anemia (AIHA) in up to 11% of patients, especially those treated with purine analogs (i.e., fludarabine, cladribine, pentostatin). Autoimmune hemolytic anemia can be a presenting feature of unrecognized CLL. The partial RBC phagocytosis by the splenic macrophages causes excessive surface membrane loss and results in spherocytes. Diagnosis is confirmed by the direct antiglobulin (Coombs') test, which detects IgG or complement on the RBC surface. Treatment of AIHA involves corticosteroids to elicit disease remission and splenectomy if steroids are not effective. However, patients presenting with acute onset of severe hemolysis and symptomatic anemia require immediate packed RBC transfusion. (Choice A) Bite cells occur secondary to phagocytes extracting denatured hemoglobin precipitates (Heinz bodies) and are usually seen in α-thalassemia and G6PD deficiency. (Choice B) Schistocytes (fragmented RBCs) are typically seen in DIC, TTP/HUS, and traumatic hemolysis. (Choice C) RBC inclusions (e.g., Howell-Jolly bodies, basophilic stippling) are usually due to precipitates of nuclear or cytoplasmic fragments (e.g., ribosomes). Common causes include asplenia, thalassemia, or heavy metal poisoning (e.g., lead). (Choice E) Tear drop cells (dacryocytes) are usually seen in conditions associated with extramedullary hematopoiesis (e.g., myelofibrosis). Myelofibrosis can present with anemia, thrombocytopenia, and elevated WBC count. However, it tends to present with immature circulating cells in the peripheral smear without generalized lymphadenopathy. This patient's mature, predominantly lymphocytic leukocytosis makes this unlikely. Educational objective: Warm agglutinin autoimmune hemolytic anemia (AIHA) is a common complication of chronic lymphocytic leukemia (CLL) and is characterized by a positive direct antiglobulin (Coombs') test and spherocytes on peripheral smear. Treatment involves steroids followed by splenectomy in refractory patients. Patients with severe hemolysis and symptomatic anemia require packed RBC transfusion. __________ References: Chronic lymphocytic leukemia and autoimmunity: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/21242190) Chronic lymphocytic leukemia-associated autoimmune hemolytic anemia. (http://www.ncbi.nlm.nih.gov/pubmed/17577769)

Question 3

A 40-year-old man comes to the emergency department after 2 episodes of coffee-ground vomiting.  He reports black, tarry stools for 1 day.  He has had no previous episodes and has no history of liver disease, jaundice, weight loss, ascites, edema, dysphagia, or illicit drug use.  He has been taking ibuprofen for lower back pain for the past 2 weeks.  He is otherwise in good general health and takes no prescription medications.
His supine blood pressure is 120/80 mm Hg and pulse is 84/min; after 1 minute of standing they are 118/76 mm Hg and 90/min.  There is no jaundice or scleral icterus.  Cardiopulmonary examination is normal.  There is mild epigastric tenderness on palpation.  There is no hepatomegaly or stigmata of chronic liver disease.  The remainder of the examination is within normal limits.
A nasogastric tube is inserted, with return of coffee ground material and some bright red blood with clots.
Laboratory results are as follows:

Urgent gastrointestinal endoscopy is scheduled.
Which of the following values for hemoglobin represents the optimal threshold for initiating blood transfusion in this patient?

Accepted Answer

Patients with gastrointestinal bleeding require adequate fluid and colloidal resuscitation prior to endoscopy to minimize complications. A 2013 landmark study showed better outcomes for patients (without comorbid illnesses) when blood transfusion was initiated when the hemoglobin level was < 7 g/dL (restrictive transfusion group) than when it was < 9 g/dL (liberal transfusion group). The restrictive transfusion group patients had fewer complications and fewer further episodes of bleeding, as well as decreased mortality. However, for patients at risk for morbidity in the setting of severe anemia, such as those with unstable coronary artery disease, goal hemoglobin level should be maintained at > 9 g/dL (rather than > 10 g/dL). Similarly, patients with hypovolemia and active bleeding may require blood transfusion despite normal hemoglobin values. Patients with suspected variceal bleeding may have worsening of the bleed if they are overtransfused to hemoglobin > 10 g/dL. Most patients included in the study, however, underwent endoscopy within 5 hours of admission. If such patients have evidence of coagulopathy (INR > 1.5 or platelets < 50000/µL), they should be transfused with fresh frozen plasma (FFP) or platelets as appropriate. The target INR is < 3 prior to endoscopy. Endoscopy can safely be performed with mild to moderate coagulopathy provided patients receive FFP during the procedure. Educational objective: The threshold for blood transfusion in patients with gastrointestinal bleeding (without comorbidity) who are hemodynamically stable is hemoglobin of < 7 g/dL. This results in fewer complications, fewer further episodes of bleeding, and decreased mortality. __________ References: Transfusion strategies for acute upper gastrointestinal bleeding. (http://www.ncbi.nlm.nih.gov/pubmed/23281973) Red blood cell transfusion is associated with increased rebleeding in patients with nonvariceal upper gastrointestinal bleeding. (http://www.ncbi.nlm.nih.gov/pubmed/23205554) Risk factors for in-hospital mortality in cirrhotic patients with oesophageal variceal bleeding. (http://www.ncbi.nlm.nih.gov/pubmed/22356784)

Question 4

A 45-year-old man comes to the emergency department after an episode of coffee-ground emesis.  During the past 6 months, he has had intermittent abdominal pain and heartburn partially relieved by over-the-counter antacids.  The patient also complains of explosive diarrhea that has not responded to dietary modifications.  Two months ago, he stopped consuming milk without relief.  He is a lifetime nonsmoker.
His blood pressure is 133/70 mm Hg and pulse is 89/min.  There are no orthostatic changes.  He has moderate epigastric tenderness without rebound.
Laboratory results are as follows:

Upper gastrointestinal endoscopy shows 2 small ulcers in the duodenal bulb with clean bases and a 1.2-cm ulcer in the very proximal jejunum.
Which of the following is most likely to establish the diagnosis in this patient?

Accepted Answer

11ec193a_960b_dc5d_853d_316b0c4e68c6_MD0002_00 This patient's presentation and endoscopic findings suggest gastrinoma (Zollinger-Ellison syndrome), which can be sporadic or found in conjunction with multiple endocrine neoplasia type 1 (MEN-1) in 20% of cases. Gastrinomas usually present in patients age 20-50 with dyspepsia, reflux symptoms, abdominal pain, weight loss, or frank gastrointestinal bleeding. Endoscopy often shows thickened gastric folds, multiple peptic ulcers, refractory ulcers despite proton pump inhibitor use, or ulcers distal to the duodenum in the jejunum. The gastrin level should be checked in suspected gastrinoma; a level < 110 pg/mL rules it out. A gastrin level > 1000 pg/mL is highly suggestive and requires checking the gastric pH, with pH > 4 ruling out gastrinoma. A pH < 4 suggests gastrinoma and requires further testing (eg, endoscopic ultrasound, somatostatin receptor scintigraphy, and CT or MRI) for localization. < A gastrin level of 110-1000 pg/mL requires a follow-up secretin stimulation test. A negative secretin test rules out gastrinoma; a positive test requires further localization testing. Gastrinoma associated with MEN-1 syndrome usually responds to proton pump therapy. However, surgery is usually preferred for sporadic gastrinomas or MEN-1 patients with uncontrolled symptoms on medical therapy. (Choice A) Gastrinoma occurs most commonly (~ 70%) in the duodenum and less commonly in the head of the pancreas and surrounding lymph nodes. Jejunal ulcer biopsy would not be as useful as the ulcers are due to surrounding acid hypersecretion rather than local tumor invasion. (Choice B) Triple therapy (proton pump inhibitor, amoxicillin, and clarithromycin) treats Helicobacter pylori, which can cause gastric and duodenal ulcers. However, this patient's multiple ulcers in different sites and diarrhea are more suggestive of gastrinoma. (Choice C) Serum 5-hydroxyindoleacetic acid is a serotonin metabolite elevated in carcinoid tumor, which usually presents with chronic diarrhea and flushing instead of gastrointestinal ulcers. (Choice E) Serum tryptase is released from mast cells and is elevated in both cutaneous and systemic mastocytosis. Patients with mastocytosis usually present with chronic abdominal pain, diarrhea, anaphylaxis or allergic-like reactions, hypotension, flushing, pruritus, syncope, fatigue, and headaches. Educational objective: Gastrinoma should be suspected in patients with multiple stomach ulcers and thickened gastric folds on endoscopy. The diagnosis is strongly suggested by serum gastrin level > 1000 pg/mL and gastric pH < 4.0. Endoscopic ultrasound, somatostatin receptor scintigraphy, and CT or MRI imaging can localize and stage the gastrinoma. < __________ References: Management of sporadic and multiple endocrine neoplasia type 1 gastrinomas. (http://www.ncbi.nlm.nih.gov/pubmed/17939142) Gastrinoma. (http://www.ncbi.nlm.nih.gov/pubmed/12057114)

Question 5

A 68-year-old man is brought to the emergency department with hypoxemic respiratory failure.  He has had worsening shortness of breath associated with fevers and a cough productive of yellowish sputum for the past 2 days.  The patient has a past medical history of stable angina, hypertension, severe chronic obstructive pulmonary disease, and peptic ulcer disease.  His trachea is intubated and mechanical ventilation is initiated.
Which of the following is most likely to decrease the risk of stress ulcers associated with gastrointestinal bleeding in this patient?

Accepted Answer

Stress ulcers can cause significant bleeding in approximately 1%-4% of critically ill patients, with mortality approaching 50%. They are often associated with hemodynamic instability, respiratory failure, and anemia warranting transfusion. Risk factors include coagulopathy, mechanical ventilation > 48 hours, prolonged ICU stay, traumatic spinal cord or brain injury, thermal injury, history of prior gastrointestinal bleeding, or high-dose corticosteroid use (Choice C). Patients having more than 1 risk factor require prophylaxis against stress ulcers. Recommended agents for prophylaxis include an oral proton pump inhibitor or intravenous H2 receptor blocker depending on the patient's ability to receive oral medications. However, these agents have been associated with a higher risk of nosocomial pneumonia and Clostridium difficile infection. Many observational studies have shown that early enteral feeding alone reduces the incidence of stress ulcers. Antisecretory therapy is more beneficial in high-risk patients and those not receiving enteral nutrition. It is unclear whether early enteral nutrition alone (compared to antisecretory therapy) is sufficient to prevent stress ulcers in high-risk patients. (Choices A, B & E) Vasopressors, antibiotics, and platelet transfusions may be used to treat critically ill patients with hemodynamic instability, possible infection, or bleeding. However, they have not been found to prevent stress-induced ulcers. Educational objective: Early enteral feeding is associated with a decreased incidence of stress ulcers in critically ill patients. Recommended agents for prophylaxis in high-risk individuals include an oral proton pump inhibitor or intravenous H2 receptor blocker depending on the patient's ability to receive oral medications. __________ References: Stress-induced ulcer bleeding in critically ill patients. (http://www.ncbi.nlm.nih.gov/pubmed/19446257) Stress ulcer prophylaxis in critically ill patients: review of the evidence. (http://www.ncbi.nlm.nih.gov/pubmed/22354363) Stress ulcer prophylaxis in the new millennium: a systematic review and meta-analysis (http://www.ncbi.nlm.nih.gov/pubmed/20711074)

Question 6

A 49-year-old woman comes to the emergency department with acute-onset hematemesis.  She has vomited blood 3 times over the past 3 hours and feels weak and light-headed.  She has a history of alcoholic cirrhosis with grade 1 esophageal varices, depression, and prior opiate abuse that is now in remission.  The patient takes sertraline, methadone, a multivitamin, folate, and thiamine daily.  She does not use tobacco or illicit drugs but drinks 10 ounces of vodka every night.
Temperature is 37.2 C (99 F), blood pressure is 90/50 mm Hg, pulse is 104/min, and respirations are 20/min.  The patient appears anxious and uncomfortable.  Her abdomen is distended and a fluid wave is present.  There is mild asterixis.  Rectal examination reveals guaiac-positive brown stools.  Skin examination is notable for multiple telangiectasias and palmar erythema.
Laboratory results are as follows:
 Intravenous fluids and octreotide are started, and urgent esophagogastroduodenoscopy is planned.
Which of the following is the best next step in management of this patient?

Accepted Answer

11ec193a_960d_d830_853d_43a055735211_MD0002_00 This patient with a history of cirrhosis, varices, and continued alcohol abuse now has hematemesis, suggesting an acute variceal hemorrhage. The immediate goals in management of acute variceal bleeding include hemodynamic resuscitation, prevention and treatment of complications, and termination of bleeding. This patient received appropriate volume resuscitation and octreotide (to constrict the splanchnic circulation and reduce blood flow to the portal vein) with plans for emergent endoscopy; however, she remains at high risk for infection. Active infection (eg, spontaneous bacterial peritonitis, urinary tract infection) is present at the time of admission in up to 20% of patients with cirrhosis and variceal bleeding, and an additional 50% may develop an acute infection during hospitalization. A short (7-day) course of prophylactic antibiotics decreases the risk of recurrent bleeding and infection, improves mortality, and shortens hospitalization. The preferred agents include norfloxacin, ciprofloxacin, or ceftriaxone. Antibiotics should be initiated prior to endoscopy, if possible, and continued even if cultures are negative. (Choice A) Abdominal ultrasound is not indicated acutely in a patient with cirrhosis who presents with gastrointestinal bleeding. However, all patients with cirrhosis, regardless of etiology, should undergo nonemergent surveillance for hepatocellular carcinoma with ultrasonography every 6 months. (Choice C) Lactulose is used in the management of hepatic encephalopathy but is not indicated for acute variceal bleeding. However, variceal bleeding is a risk factor for hepatic encephalopathy, so the patient should be monitored for this complication. (Choice D) Current guidelines recommend transfusion of packed red blood cells to maintain hemoglobin around 7-8 g/dL in patients with active variceal bleeding. Overtransfusion should be avoided as volume overload can lead to rebleeding episodes due to rebound portal hypertension. (Choice E) Coagulopathy (INR >2) and thrombocytopenia (platelets < 50,000/mm³) can be corrected with transfusion of fresh frozen plasma and platelets, respectively. The patient does not require transfusion at this time. ³ Educational objective: Treatment of patients with active variceal bleeding includes hemodynamic resuscitation, intravenous octreotide, prophylactic antibiotics, and endoscopic therapy. Antibiotics are continued for a total of 7 days even if cultures remain negative. __________ References: Antibiotic prophylaxis in variceal hemorrhage: timing, effectiveness and Clostridium difficile rates. (http://www.ncbi.nlm.nih.gov/pubmed/21072894) Variceal bleeding in portal hypertension: bacterial infection and comparison of efficacy of intravenous and per-oral application of antibiotics-a randomized trial. (http://www.ncbi.nlm.nih.gov/pubmed/16148557)

Question 7

A 70-year-old woman is brought to the emergency department after she tripped and fell at home while getting out of a bathtub.  She did not lose consciousness but does have headache and mild right arm pain.  Her medical history is significant for advanced breast cancer treated with radical mastectomy and chemotherapy a year ago.
CT of the head is unremarkable.  Radiographs of the upper extremities show bone lesions consistent with metastases, but no evidence of fracture.  Her serum creatinine level is 1.4 mg/dL (creatinine clearance 30 mL/min), serum calcium level is 9.6 mg/dL, and alkaline phosphatase level is 220 U/L.
The patient is most likely to benefit from which of the following?

Accepted Answer

In patients with bone metastases, osteoclast-inhibiting agents such as denosumab and bisphosphonates significantly decrease the risk of skeletal-related events (SREs) (eg, fracture, skeletal instability/loss, spinal cord compression) and can delay symptom onset, fracture formation, need for irradiation, development of hypercalcemia, and possibility of surgical treatment. Denosumab is a fully human monoclonal antibody that binds to receptor activator of nuclear factor kappa-B ligand (RANKL) and prevents its interaction with RANK, which is an important step in osteoclast activation. Several large randomized trials have shown that denosumab significantly delays SRE onset compared with zoledronic acid (bisphosphonate). Denosumab can be used in a variety of solid tumors. Major side effects are similar to those seen with high potency bisphosphonates (eg, osteonecrosis of the jaw, hypocalcemia). Hypocalcemia and vitamin D deficiency must be corrected before starting therapy. Unlike with zoledronic acid (contraindicated for creatinine clearance <35 mL/min as in this patient), renal dose adjustments are not required, although renal function should be monitored. (Choice A) Alendronate is an oral bisphosphonate used for prevention and treatment of osteoporosis. It has poor bioavailibility (only 1%-5%). For management of bone metastases, parenteral bisphosphonates (eg, zoledronic acid, pamidronate) or oral ibandronate are indicated. Bisphosponates have more analgesic and cost benefits compared to denosumab. However, they are not recommended in renal failure. (Choice B) Calcium decreases the risk of bisphosphonate-induced hypocalcemia, and vitamin D is helpful in breast cancer patients who are at risk for vitamin D deficiency. However, they do not significantly impact the evolution of bone metastases. (Choice C) Calcitonin is indicated for Paget disease and is an adjunct in treating hypercalcemia. However, it does not significantly improve bone metastases. (Choice E) Irradiation can provide symptomatic relief of bone pain in patients with bone metastases, but it is only rarely performed for the prevention of SREs from bone metastases. In addition, this patient does not have significant bone pain at metastasis sites. Educational objective: Metastatic cancer patients with bone metastases are susceptible to skeletal-related events (SREs) (eg, fracture, skeletal instability/loss, spinal cord compression). Denosumab and the intravenous bisphosphonates, zoledronic acid and pamidronate, have been shown to prevent SREs and decrease morbidity. Denosumab does not require renal dose adjustments. __________ References: Denosumab compared with zoledronic acid for the treatment of bone metastases in patients with advanced breast cancer: a randomized, double-blind study. (http://www.ncbi.nlm.nih.gov/pubmed/21060033)

Question 8

A 78-year-old man is brought to the emergency department with abdominal pain.  According to his wife, he has had epigastric discomfort for the past 2 days; this morning he refused to get out of bed and appeared confused.  Past medical history is significant for diet-controlled diabetes mellitus, coronary artery disease with stable angina, hypertension, and gastroesophageal reflux disease.
On examination, the patient is lethargic.  His temperature is 38 C (100.4 F), blood pressure is 144/90 mm Hg, pulse is 112/min and irregular, and respirations are 20/min.  Chest is clear on auscultation.  There are no heart murmurs.  The abdomen is tender to palpation in the epigastric and right upper quadrant areas.  His skin is warm and there are no rashes.
Laboratory results are as follows:

ECG reveals atrial fibrillation with no significant ST segment or T wave changes.  Abdominal ultrasound shows several small gallstones without wall thickening or edema around the gallbladder.  Common bile duct size is normal.
Which of the following is the best next step in managing this patient?

Accepted Answer

11ec193a_9612_e14a_853d_f3443944026f_MD0002_00 Fever, lethargy, abdominal pain, and epigastric tenderness in the setting of previously undiagnosed and untreated atrial fibrillation (AF) are most suggestive of acute mesenteric ischemia. Ischemia occurs due to abrupt occlusion of arterial flow from embolus or thrombus in the setting of atherosclerotic disease and/or AF without adequate anticoagulation. This patient's high CHA₂DS₂-VASc score places him at increased risk of systemic thromboembolism. CHA₂DS₂-VASc score Patients typically present with sudden onset of severe periumbilical pain that appears to be out of proportion to examination findings. Laboratory studies typically show leukocytosis, elevated amylase levels, and metabolic acidosis due to increased serum lactate levels. CT or MR angiography of the abdomen is typically used for diagnosis in stable patients. Conventional arteriography may be required when the diagnosis remains uncertain. (Choices A and B) Percutaneous cholecystostomy is usually reserved for high-risk patients with acute cholecystitis who are too ill to undergo cholecystectomy. This patient's ultrasound does not show gallbladder wall thickening or edema, making acute cholecystitis a less likely diagnosis. Similarly, cholescintigraphy (HIDA scan) is occasionally performed in patients with suspected cholecystitis if the diagnosis remains uncertain following abdominal ultrasound. (Choice D) Urgent direct current cardioversion for AF is indicated only in patients with active chest pain, severe acute heart failure, or hemodynamic instability. Moreover, cardioversion in patients with AF of unknown duration will increase the risk of systemic thromboembolism. (Choice E) Transesophageal echocardiogram can reveal an intracardiac source of embolus (left atrium or left atrial appendage); however, it will not change the immediate management of this patient. Therefore, CT angiography of the abdomen should be performed as an initial diagnostic test in this setting. Educational objective: The diagnosis of acute mesenteric ischemia depends on a high index of clinical suspicion in patients with known risk factors for thromboembolic disease (eg, atrial fibrillation, atherosclerosis). CT or MR angiography of the abdomen is typically used for diagnosis in stable patients. __________ References: Ischemic bowel syndromes. (http://www.ncbi.nlm.nih.gov/pubmed/23402466) The diagnosis of acute mesenteric ischemia: A systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/24238311)

Question 9

A 20-year-old woman comes to the emergency department complaining of nausea and vomiting.  She awoke that morning with the sudden onset of nausea and vomiting.  She vomited about 10 times and became concerned when she noticed blood in the vomitus.  The patient has no dysphagia or odynophagia.  Her other medical problems include a history of menorrhagia and bulimia.  She takes naproxen daily for chronic low back pain and does not use tobacco, alcohol, or illicit drugs.
Her blood pressure is 109/60 mm Hg, pulse is 106/min, and respirations are 14/min.  Examination shows dry mucous membranes.  The abdomen is soft and nontender.  There is no hepatomegaly or splenomegaly.
Laboratory results are as follows:

Test for stool occult blood is negative.
Which of the following is the most appropriate next step in management?

Accepted Answer

This patient's presentation suggests Mallory-Weiss (MW) tear. MW tear is an upper gastrointestinal mucosal tear due to a sudden increase of intra-abdominal pressure from forceful retching. This can lead to submucosal arterial or venule plexus bleeding. Bleeding is self-limited (24-48 hours) in most patients. However, life-threatening bleeding can occur. Patients typically present with epigastric pain radiating to the back and hematemesis after extended nausea and vomiting. Esophagogastroduodenoscopy (EGD) is preferred for diagnosis and differentiating MW tear from esophagitis due to other conditions (eg, reflux, infectious, pill-induced). MW tears are usually located near the distal esophagus and proximal stomach. Most physicians also use proton pump inhibitors even though the benefit in MW tears is not clear. (Choice A) Angiographic arterial embolization is rarely required in patients with refractory bleeding. (Choice B) Barium swallow is indicated for patients with dysphagia (eg, Schatzki rings or motility disorders). It would not be able to properly identify a MW tear. (Choice D) Based on data from observational studies, most urgent endoscopic procedures can be performed safely if the INR is < 1.5-2.5. Endoscopic therapy in these patients has similar success rate and rebleeding risk as non-anticoagulated patients. (Choice E) Intravenous octreotide is commonly used in the management of variceal bleeding due to its ability to reduce splanchnic blood flow. It has no role in the treatment of MW tears. Educational objective: Mallory-Weiss tear is an upper gastrointestinal mucosal tear due to a sudden increase of intra-abdominal pressure from forceful retching. Endoscopy is preferred for diagnosis. Most patients have self-limited (24-48 hours) bleeding with spontaneous healing of ulcers. Patients with active bleeding usually require endoscopic treatment with epinephrine injection, cautery, or hemoclip application. __________ References: Mallory-Weiss tear: predisposing factors and predictors of a complicated course. (http://www.ncbi.nlm.nih.gov/pubmed/11693318) Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation. (http://www.ncbi.nlm.nih.gov/pubmed/19091393) Impact of anticoagulation on rebleeding following endoscopic therapy for nonvariceal upper gastrointestinal hemorrhage. (http://www.ncbi.nlm.nih.gov/pubmed/17100959)

Question 10

A 66-year-old man comes to the emergency department due to abdominal pain and nausea.  He has had no vomiting or bloody stools.  Yesterday he underwent a screening colonoscopy, which revealed scattered diverticulosis and 2 polyps that were then removed.  The patient's other medical conditions include hypertension and gastroesophageal reflux disease.
Temperature is 38.1 C (100.6 F), blood pressure is 110/70 mm Hg, and pulse is 98/min.  Mucous membranes are moist.  The abdomen is tender in the periumbilical and left lower quadrants with no rebound tenderness.
Laboratory results are as follows:
 Upright abdominal radiographs show no free air under the diaphragm.
Which of the following is the best next step in management of this patient?

Accepted Answer

This patient's abdominal pain following colonoscopy with biopsies is concerning for perforation at the polypectomy site. Perforation can occur due to direct mechanical trauma from the colonoscope, barotrauma from the colonoscopy pressure, or electrocautery injury during polypectomy. Screening colonoscopy has <0.1% risk of perforation, but interventions (eg, dilatation) can increase the rate up to 18%. Perforations can be retroperitoneal if involving the ascending or descending colon or the splenic and hepatic flexures, or intraperitoneal if the transverse or sigmoid colon is involved. Patients with perforations typically have abdominal pain or distension and may also have fever and chest or scapular pain. Peritoneal signs (eg, rebound tenderness, decreased bowel sounds, abdominal wall rigidity) eventually develop. Immediate abdominal x-ray (plain and upright or lateral decubitus) and upright chest x-ray should be obtained to look for free air. Patients in whom there is a high clinical suspicion for perforation but with negative x-rays should undergo abdominal and pelvic CT scan with water-soluble contrast (eg, Gastrografin). CT scan with contrast is more sensitive than plain films for detecting extraluminal air and subtle perforation. Management involves broad-spectrum antibiotics and surgical consultation. (Choice B) Noncontrast CT scan may miss subtle perforations and is not recommended. (Choice C) Sigmoidoscopy is contraindicated in the setting of a perforation as insufflating air during the procedure would significantly worsen the perforation and peritonitis. (Choices D and E) This patient has fever and acute abdominal pain. He requires immediate investigation for possible causes (eg, perforation, abscess) and intravenous broad-spectrum antibiotics; reassurance or oral antibiotics will delay necessary therapy and likely worsen his clinical outcome. Educational objective: Perforation from routine endoscopic procedures is uncommon and typically occurs from mechanical trauma, barotrauma, electrocautery, or therapeutic interventions. Immediate abdominal (upright or lateral decubitus) and upright chest radiographs can confirm a perforation. Patients with high clinical suspicion for perforation and negative x-rays should undergo CT scan with a water-soluble contrast agent, which can detect subtle perforation. __________

Question 11

An 82-year-old woman is brought to the emergency department after 2 episodes of large bloody bowel movements.  She has no abdominal pain or vomiting.  Her past medical history is significant for paroxysmal atrial fibrillation and hypertension.  She takes daily low-dose aspirin.
Her blood pressure is 130/80 mm Hg, pulse is 88/min, and respirations are 14/min.  Abdominal examination reveals no tenderness or organomegaly.
Laboratory results are as follows:

While in the emergency department, the patient has another bloody bowel movement accompanied by transient dizziness and diaphoresis.  Upper gastrointestinal endoscopy and colonoscopy reveal no source of bleeding.
Which of the following is the most likely additional physical finding on chest examination?

Accepted Answer

Lower gastrointestinal bleeding is typically due to anatomic conditions (eg, diverticulosis), vascular causes (eg, arteriovenous malformation [AVM]), inflammatory diseases (eg, inflammatory bowel disease), or malignancy. This patient's normal gastrointestinal endoscopy and colonoscopy make diverticulosis, malignancy, inflammatory bowel disease, and hemorrhoids less likely. She likely has intestinal angiodysplasia or AVM, which are abnormal connections between veins and arteries that can erode through the gastrointestinal mucosa and bleed. Angiodysplasia usually presents in patients age > 60 and can occur in 1 or multiple areas of the gastrointestinal tract. Angiodysplasia is often discovered in patients with underlying aortic stenosis or end-stage renal disease. In aortic stenosis, turbulent blood flow through the valve causes disruption of von Willebrand multimers (acquired von Willebrand disease). This leads to increased risk of bleeding, resulting in identification of angiodysplasia. The bleeding tends to improve with aortic valve replacement, but patients usually require endoscopic treatment for active bleeding. This patient's physical examination would likely indicate a systolic crescendo-decrescendo murmur that radiates to the carotid arteries. Uremic platelet dysfunction in end-stage renal disease also increases bleeding risk, leading to identification of angiodysplasia. (Choices B, C, and D) Holosystolic murmur is due to tricuspid regurgitation, mitral regurgitation, and ventricular septal defect. Aortic regurgitation leads to a diastolic decrescendo murmur. Mitral stenosis presents with a mid-diastolic rumble and is unlikely in this elderly patient. These valvular conditions are usually not associated with angiodysplasia. (Choice E) Pericardial knock is an earlier-than-normal S3 that occurs due to restricted ventricular filling during diastole. It is usually seen in constrictive pericarditis and is usually not associated with angiodysplasia. Educational objective: Arteriovenous malformation can present with significant lower gastrointestinal bleeding and chronic iron deficiency anemia. It is found more commonly in elderly patients with end-stage renal disease and aortic stenosis. __________ References: Diagnosis and management of lower gastrointestinal bleeding. (http://www.ncbi.nlm.nih.gov/pubmed/19881516) An epidemiological study of Heyde's syndrome: an association between aortic stenosis and gastrointestinal bleeding. (http://www.ncbi.nlm.nih.gov/pubmed/15473467)

Question 12

An 18-year-old man comes to the emergency department due to retrosternal chest pain and pain with swallowing.  The patient has a burning pain that began abruptly the previous morning and then gradually worsened.  He has been limiting himself to soft foods as the pain is much worse with swallowing solids.  The patient has a history of tension headaches that have become more frequent lately, which he attributes to long hours of studying for exams.  His only medication is ibuprofen as needed for headaches, and he has no drug allergies.  The patient's mother has Crohn disease.  He drinks alcohol socially, smokes a half pack of cigarettes daily, and does not use illicit drugs.  The patient is sexually active and uses condoms inconsistently.
Temperature is 36.7 C (98.1 F), blood pressure is 118/76 mm Hg, pulse is 88/min, and respirations are 14/min.  There are no oropharyngeal lesions or palpable lymphadenopathy.  The lung auscultation and cardiac examination are normal.  The abdomen is soft without rebound or guarding.
Which of the following is the most appropriate next step in management of this patient's symptoms?

Accepted Answer

11ec193a_9613_a49b_853d_a18a68c92bf1_MD0002_00 This patient with acute substernal chest pain and odynophagia associated with ibuprofen use likely has medication-induced esophagitis (MIE). MIE is due to direct mucosal injury, typically occurring when a pill becomes lodged at a narrow point in the esophagus. Risk factors include abnormal esophageal anatomy, large pill size, pill ingestion while supine, and inadequate fluid intake. Common offending medications include nonsteroidal anti-inflammatory drugs, bisphosphonates, potassium chloride, iron supplements, and tetracyclines. Treatment of MIE includes discontinuation of the offending medication and supportive measures (eg, fluids, pain control) as needed. Some experts also advise a trial of a proton pump inhibitor or sucralfate. Upper endoscopy is indicated in patients with severe or atypical symptoms (eg, hematemesis, weight loss) or those who continue to have symptoms 1 week after drug withdrawal to evaluate for stricture or secondary causes (Choice E). Patients who need to take a potentially offending medication should be instructed to take it with at least 8 oz of water and remain upright for at least 30 minutes after ingestion. (Choice A) Barium esophagram can be used to diagnose anatomic abnormalities and neuromuscular disorders (eg, achalasia); however, it has limited diagnostic value in MIE unless there is concern for extrinsic compression leading to pill retention. (Choice B) The most common cause of HIV-associated odynophagia is Candida esophagitis. However, this condition is usually associated with dysphagia and oral thrush. HIV testing should be offered to any patient with high-risk sexual activity, but it is unlikely to affect management in this case. (Choice C) Eosinophilic esophagitis can cause chest pain and heartburn. It is treated primarily with dietary restrictions, although swallowing an inhaled fluticasone spray can be considered as second-line therapy. However, eosinophilic esophagitis often presents with dysphagia, and this patient's frequent ibuprofen ingestion and odynophagia make MIE more likely. Educational objective: Medication-induced esophagitis is due to direct mucosal injury and is frequently noted with nonsteroidal anti-inflammatory drugs, tetracyclines, bisphosphonates, iron supplements, and potassium chloride. Discontinuation of the offending medication is usually adequate treatment, but additional evaluation is indicated for patients with severe, atypical, or persistent symptoms. __________ References: Clinical and endoscopic characteristics of drug-induced esophagitis. (http://www.ncbi.nlm.nih.gov/pubmed/25152603)

Question 13

A 44-year-old construction worker comes to the emergency department with nausea and fatigue over the last 2 days.  He strained his back at work 7 days ago.  He could not move for several days and took over-the-counter painkillers and applied hot packs.  The patient still has significant back pain and limited mobility.  He smokes 1 pack of cigarettes a day.  He drinks alcohol daily and heavily on weekends.  In addition, he also admits to using intravenous heroin on occasion.
He was hospitalized for pneumonia 6 months ago and treated with intravenous antibiotics.  The echocardiogram during that admission showed normal left ventricular systolic function, mildly dilated right ventricle, and mild pulmonary hypertension.
His temperature is 37.2° C (99° F), blood pressure is 94/50 mm Hg, and pulse is 112/min.  There is mild scleral icterus.  Several needle tracks are seen on both forearms.  No heart murmurs are present.  The lungs are clear.  There is no abdominal distention.  Moderate right upper-quadrant tenderness is present.  The spleen is not palpable.  There is no peripheral edema.
Laboratory results are as follows:

Which of the following is the most likely cause of this patient's current condition?

Accepted Answer

Acetaminophen toxicity should be suspected in any patient presenting with markedly elevated hepatic aminotransferases or acute liver failure. Acetaminophen toxicity has become the most common cause of acute liver failure in the United States and is likely to occur with either a single ingestion > 250 mg/kg or > 12 g within a 24-hour period. Older age, malnutrition, and concurrent intake of medications that induce the cytochrome P450 enzyme (eg, phenytoin or trimethoprim-sulfamethoxazole) are additional risk factors. Chronic alcoholism is also a risk factor. However, acute ingestion of alcohol does not increase the risk and may actually be protective due to its competition with the drug for the same cytochrome P450 enzyme. Unlike most other causes of hepatitis, acetaminophen-associated hepatitis is acute in onset and progresses rapidly. During the first 24 hours of toxicity, patients may be asymptomatic or experience altered mentation or nausea and vomiting. As the condition progresses, patients become more lethargic and, in severe cases, comatose. Patients may develop right upper-quadrant abdominal pain, oliguria, jaundice, and spontaneous bleeding. Elevation of hepatic aminotransferases may not be present until 8-12 hours after ingestion. The level then rises steadily over the course of 3-4 days and often exceeds 10,000 IU/L if not treated with N-acetylcysteine. (Choice A) The ratio of serum aspartate aminotransferase and alanine aminotransferase is usually > 2.0 in alcoholic hepatitis. Serum aminotransferases in alcoholic hepatitis are usually < 300 IU/L and rarely > 500 IU/L. (Choice B) Liver abscess usually presents with fever and right upper-quadrant pain. Transaminases can be mildly elevated but will not number in the thousands. Alkaline phosphatase is usually elevated depending on the size and obstruction the abscess causes. (Choice C) Acute hepatitis C is often asymptomatic and rarely causes hepatic failure. Chronic hepatitis C virus infection is usually slowly progressive and hepatic aminotransferase is rarely > 10 times the normal limit. (Choice E) Severe pulmonary hypertension (right heart failure) can cause passive hepatic congestion, which usually manifests with jaundice. Total bilirubin is generally < 3 mg/dL. Alkaline phosphatase and aminotransferases are only mildly elevated. Educational objective: Patients presenting with markedly elevated hepatic aminotransferases should raise suspicion for acetaminophen toxicity. N-acetylcysteine is the antidote of choice. __________ References: A review of acetaminophen poisoning. (http://www.ncbi.nlm.nih.gov/pubmed/22998987) Acetylcysteine for acetaminophen poisoning. (http://www.ncbi.nlm.nih.gov/pubmed/18635433)

Question 14

A 64-year-old man comes to the emergency department with sudden onset of epigastric abdominal pain and vomiting.  He attended a colleague's retirement party the night before and admits that he had "a little too much to drink."  The patient vomited twice when he got home and noticed abdominal pain after the second vomiting episode.  He thought the pain was related to "heartburn" and took extra-strength calcium carbonate antacids with little relief.  He tried to sleep, but the severe pain kept him awake.  The patient has a history of hypertension and takes amlodipine.  He is a current smoker with a 40-pack-year history.
His temperature is 38.0° C (100.4° F), blood pressure is 108/64 mm Hg, pulse is 110/min, and respirations are 18/min.  Pulse oximetry is 96% on room air.  Examination shows a man in moderate distress.  There are normal first and second heart sounds.  Decreased breath sounds are heard on the left lower lung field with dullness to percussion.  There is both right upper-quadrant and epigastric tenderness without rebound or guarding.
Chest x-ray reveals pneumomediastinum and a moderate-sized left pleural effusion.
Which of the following is the best next step in managing this patient?

Accepted Answer

11ec193a_960f_d403_853d_d9c8bc610f3f_MD0002_00 This patient's presentation suggests spontaneous esophageal rupture (SER). SER (Boerhaave syndrome) is usually due to prolonged nausea and vomiting causing an acute rise of intraesophageal pressure combined with negative intrathoracic pressure. This leads to a transmural esophageal tear and acute barotrauma with esophageal air/fluid leaking into surrounding areas (eg, mediastinum, pleura). Although it is a rare diagnosis, SER has a 20% mortality rate, usually due to infectious complications (eg, empyema, mediastinitis, septic shock). Patients usually present with vomiting/retching and chest/upper abdominal pain with rapid progression to odynophagia, fever, dyspnea, and septic shock. Physical examination may show subcutaneous emphysema but is not a sensitive finding. Chest x-ray may reveal pneumomediastinum or pleural effusions. Pleural fluid analysis is typically exudative with low pH and very high amylase (> 2500 IU). Computed tomography or contrast esophagography with Gastrografin is preferred for confirming the diagnosis. (Choice A) Abdominal ultrasound is used to examine the internal organs of the abdomen but would not be as sensitive in evaluating for suspected esophageal rupture in this patient. (Choice B) Chest tube placement would clear the pleural effusion but would not address the underlying serious perforation. (Choice D) Esophagogastroduodenoscopy (EGD) with insufflation of air can extend the perforation and introduce air into the mediastinum. However, when done under a controlled setting in the operating room, EGD may be useful for select patients to directly visualize the perforation and plan treatment. (Choice E) A high pleural fluid amylase can occur in acute pancreatitis, chronic pancreatitis with pleural effusion, and esophageal rupture. Serum amylase is high in acute pancreatitis, which is not usually associated with pneumomediastinum, as seen in this patient. Educational objective: Spontaneous esophageal rupture is due to acute barotrauma from vomiting or retching that leads to a transmural tear. Patients classically present with forceful retching followed by severe retrosternal chest and upper abdominal pain. Diagnosis is confirmed with computed tomography or esophagography with gastrografin. __________ References: Boerhaave syndrome: a diagnostic conundrum. (http://www.ncbi.nlm.nih.gov/pubmed/21686835) Evolving options in the management of esophageal perforation. (http://www.ncbi.nlm.nih.gov/pubmed/15063302)

Question 15

A 58-year-old woman comes to the emergency department with 5 days of progressive headaches and dizziness.  She is a business executive who is very active in her spare time.  She takes no medications.
Her vital signs are within normal limits.  Examination shows bilateral normal reflexes and sensation and no neck stiffness.  Pupils are equal and reactive to light.  Gag reflex is intact.  There is no peripheral lymphadenopathy.
Laboratory results are as follows:

CT scan of the head with contrast shows a solitary frontal 2x3 cm lesion at the gray-white matter junction with vasogenic edema confirmed on magnetic resonance imaging.  CT scan of the chest, abdomen, and pelvis reveals a spiculated 2.5 cm right upper-lung mass with ipsilateral bronchial lymphadenopathy but no other evidence of metastatic disease.
Which of the following is the most appropriate next step in management of this patient's brain lesion?

Accepted Answer

11ec193a_9618_86a5_853d_d122bc412a27_MD0002_00 Nearly 40% of patients with systemic cancer develop brain metastases, usually through hematogenous spread. Imaging features suggesting metastatic disease include circumscribed margins, location at the gray-white matter junction, patterns of vasogenic edema, and multiple lesions. The most common underlying primary tumors are lung, renal cell, breast, colorectal, and melanoma. This patient likely has primary lung cancer, which may be small cell (SCLC) or non-small cell (NSCLC). Brain metastases from SCLC appear to respond initially to chemotherapy, but studies have shown variable overall response rates without significant survival benefit. Adding whole-brain radiation (WBRT) improves the response rate to chemotherapy but without significant survival benefit. NSCLC is not as chemosensitive as SCLC, and brain metastases respond better to WBRT and/or surgical resection. As a result, surgical resection is usually considered for brain metastases due to SCLC or NSCLC. Options for treating solitary lung-brain metastases include surgical resection followed by WBRT or stereotactic radiosurgery with or without WBRT. Surgery or stereotactic radiosurgery followed by WBRT reduces the risk of tumor recurrence and the likelihood of neurologic death (Choice E). Surgical success depends on resectability, feasibility of decreasing mass effect, proximity to vital areas, age, and performance status. Patients with a resected solitary lung-brain metastasis have a median survival of 40 weeks. This patient with likely primary lung cancer should undergo resection without the need for brain biopsy. (Choice B) Systemic chemotherapy has poor penetration of the blood-brain barrier and is not very effective for brain metastasis. Systemic chemotherapy should be started after treatment of brain metastasis. (Choice C) This patient has good performance status, meets the criteria for resection, and is interested in treatment. Hospice care is not indicated at this time. Palliative care services can be added to assist in overall management of this patient once the brain metastasis is addressed. (Choice D) Sunitinib is a multi-targeted receptor tyrosine kinase inhibitor that is indicated for treating renal cell carcinoma, gastrointestinal stromal tumors, and advanced pancreatic neuroendocrine tumors, not for metastatic lung cancer to the brain. Educational objective: Patients with solitary brain metastasis benefit from surgery or stereotactic radiation followed by whole-brain radiation. __________ References: Nonsmall cell lung cancer presenting with synchronous solitary brain metastasis. (http://www.ncbi.nlm.nih.gov/pubmed/16572401)

Question 16

A 65-year-old man comes to the emergency department because of worsening generalized itching for 7 days.  He has experienced abdominal discomfort, bloating, and decreased appetite for several weeks.  He states that he has lost 10-12 lbs (4.5-5.4 kg) during this time, which he attributes to excessive stress at work.  He denies nausea, vomiting, diarrhea, easy bleeding, or bruising.
His temperature is 36.9 C (98.4 F), blood pressure is 123/70 mm Hg, and pulse is 78/min and regular.  On examination, he has icteric conjunctivae and skin.  He has bilateral diffuse scratch marks.  There is mild tenderness on palpation of his right upper abdominal quadrant.  The tip of the spleen is not palpable.
Laboratory results are as follows:

Abdominal ultrasound reveals an enlarged liver with dilated intrahepatic bile ducts.  A CT scan of the abdomen reveals an ill-defined 3.5 cm pancreatic mass and several low-attenuating foci in the liver consistent with metastasis.
Which of the following would be the best next step in managing this patient?

Accepted Answer

Pancreatic cancer has the highest mortality among all gastrointestinal cancers and is diagnosed at a median age of 71. The majority (80-85%) of patients present with unresectable or metastatic disease. Median survival is typically 3 to 6 months. Chemotherapy is a consideration for patients with locally advanced disease that is not surgically resectable. However, the treatment is palliative for metastatic pancreatic cancer to the liver. Up to 70% of patients with pancreatic cancer develop symptomatic biliary obstruction, which increases the risk for cholangitis. Biliary endoscopic stenting is preferred for relieving the obstruction prior to considering the administration of systemic chemotherapy (Choice B). Surgical biliary decompression (e.g., cholecystojejunostomy or choledochojejunostomy) is reserved for patients who cannot undergo endoscopic stenting due to technical reasons (Choice A). (Choice D) Narcotic medications are often required for moderate to severe pain associated with locally advanced pancreatic cancer; however, these medications can exacerbate itching due to histamine release. This patient's main complaint is itching, not pain. (Choice E) Ursodeoxycholic acid reduces hepatic cholesterol secretion and fractional intestinal cholesterol reabsorption to decrease biliary cholesterol content. It can possibly prevent gallstone formation and dissolve gallstones in primary biliary cirrhosis but is not as beneficial in metastatic pancreatic cancer patients with obstructive jaundice. Educational objective: Pancreatic cancer patients commonly present with biliary obstruction. Endoscopic stent placement is preferred to relieve biliary obstruction and prevent cholangitis. __________ References: Treatment of pancreatic cancer: challenge of the facts (http://www.ncbi.nlm.nih.gov/pubmed/12925907) Palliative therapy for pancreatic/biliary cancer (http://www.ncbi.nlm.nih.gov/pubmed/15833477)

Question 17

A 72-year-old man is brought to the emergency department because of sudden onset shortness of breath and sharp left-sided chest pain.  He denies fever, loss of consciousness, or orthopnea.  He was diagnosed with metastatic pancreatic cancer three months ago.
Examination reveals clear lungs with normal first and second heart sounds.  The abdomen is soft and non-tender.  There is trace edema involving the right leg.  Neurologic examination is within normal limits.
Laboratory results are as follows:

His chest-x ray is clear.  Ultrasound of the right leg shows a thrombus in the popliteal vein.  CT angiogram of the chest reveals bilateral pulmonary emboli.
Which of the following would be the most effective long-term treatment to prevent recurrent thromboembolism in this patient?

Accepted Answer

Patients with cancer have a 4-7 fold increased risk of venous thromboembolism (VTE). Long-term VTE treatment is different in cancer patients than patients without cancer. Low molecular weight heparin (LMWH) is more effective than vitamin K antagonists (e.g., warfarin) in reducing the risk of recurrent VTE in cancer patients (while on therapy), and they do not significantly increase the risk of bleeding (Choice C). However, LMWH is not associated with improved survival in these patients. Though more effective, other factors must be taken into consideration when prescribing LMWH, such as patient preference (e.g., needle vs. pills), comorbidities (e.g., renal insufficiency), and cost (e.g., copays). (Choice B) Due to its short half-life, unfractionated heparin is used for inpatient VTE treatment in patients with a high risk of bleeding. However, it is not appropriate for long-term use. (Choice D) This patient has no contraindications for anticoagulation and an IVC filter is not needed. Educational objective: Low molecular weight heparin (LMWH) is more effective than vitamin K antagonists (e.g., warfarin) in reducing the risk of recurrent venous thromboembolism in cancer patients. However, LMWH is not associated with improved survival in these patients. __________ References: Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in cancer. (http://www.ncbi.nlm.nih.gov/pubmed/12853587) Management of venous Thromboembolism in cancer: a brief review of risk-benefit approaches and guidelines' recommendations. (http://www.ncbi.nlm.nih.gov/pubmed/20464888)

Question 18

A 36-year-old woman comes to the emergency department with abdominal pain and distention that started 5 days earlier and has become progressively worse. She initially thought she was experiencing bloating but the symptoms persisted despite poor appetite. The patient has a history of migraines. She underwent ovarian cyst resection 5 years ago. Her medications include over-the-counter analgesics, oral contraceptive pills, and daily multivitamins. She does not use tobacco, alcohol, or illicit drugs. Her temperature is 37.2° C (99° F), blood pressure is 110/70 mm Hg, and pulse is 98/min. BMI is 25 kg/m². The estimated jugular venous pressure is 7 mm H₂O. Lungs are clear to auscultation. No murmurs are heard. The abdomen is distended and there is positive fluid shift test. The liver edge is tender and is palpated 4 cm below the right costal margin. The spleen is not palpable. There is trace lower-extremity edema. Liver function test results are as follows: Ultrasound-guided paracentesis yields 1.5 L of clear fluid. Fluid analysis shows a white cell count of 120/mm³ and albumin of 2.4 g/L. Cytology is pending. Which of the following is the most likely diagnosis?

Accepted Answer

11ec193a_960e_c292_853d_058e2d296708_MD0002_00 This patient's clinical presentation suggests Budd-Chiari syndrome. Budd-Chiari syndrome is due to thrombosis of the hepatic/intrahepatic veins or suprahepatic inferior vena cava and occurs most commonly in women in their 30s and 40s. The condition may be idiopathic or due to etiologies such as malignancy (eg, hepatocellular carcinoma is most common), myeloproliferative diseases, oral contraceptive use, pregnancy, or hypercoagulable states. Acute Budd-Chiari syndrome (20% of patients) presents with severe right upper quadrant abdominal pain, hepatomegaly, jaundice, ascites, and possible variceal bleeding. Serum aminotransferases are usually elevated, but not as high as in acute viral hepatitis (Choice B). Untreated disease may progress to encephalopathy and fulminant liver failure. Subacute and chronic Budd-Chiari syndrome may be asymptomatic for weeks to several months due to partial hepatic vein occlusion. Chronic hepatic vein occlusion may lead to hypertrophy of the caudate lobe of the liver, which eventually compresses the infrahepatic inferior vena cava to cause ascites and lower-extremity edema. Patients eventually develop cirrhosis, portal hypertension, and normal to mildly elevated liver function studies. However, jaundice and encephalopathy are less common. Diagnosis can be made by Doppler ultrasound with flow, CT scan, or magnetic resonance angiography showing occlusion or poorly visualized flow in the hepatic veins. Venography (gold standard) is suggested if these tests are nondiagnostic and may show venous occlusion with a "spider-web" pattern of hepatic collaterals. Ascites fluid analysis usually shows a high serum to ascites albumin gradient (SAAG) > 1.1 g/dL, indicating portal hypertension. Liver biopsy is reserved for patients with inconclusive initial investigations. CT scan Treatment involves diuretics, anticoagulation, angioplasty with stenting for select patients, and possible thrombolytics (only in acute/subacute disease). Patients not responding to these measures may require transjugular intrahepatic portosystemic shunt, surgical shunts, or liver transplant. (Choice A) In acute acetaminophen overdose, serum aminotransferase levels are markedly elevated (> 3000 IU/L) with more rapid progression of hepatic injury. This patient's clinical presentation of abdominal distention and pain for 5 days, as well as low levels of aminotransferase elevation, are less consistent with acetaminophen overdose. (Choice D) Peritoneal carcinomatosis usually presents with large weight loss, shortness of breath, and abdominal pain. Ascites often develops due to large tumor burden; fluid studies without liver involvement often show SAAG < 1.1 g/dL. (Choice E) Primary biliary cirrhosis usually presents with fatigue, pruritus, markedly elevated alkaline phosphatase, normal to slightly elevated serum aminotransferases, and possible hyperpigmented skin. Educational objective: Budd-Chiari syndrome (thrombosis of hepatic veins) should be suspected in young women who present with rapid onset of abdominal pain and ascites. Diagnosis is made by ultrasound with Doppler flow, computed tomography scan, or magnetic resonance angiography. Treatment includes anticoagulation, treatment of liver complications, angioplasty, transjugular intrahepatic portosystemic shunts, or liver transplant. __________ References: An update on the diagnosis and management of Budd-Chiari syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/23237258) Budd-Chiari syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/22997363)

Question 19

A 20-year-old African American woman with sickle cell disease comes to the emergency department with complaints of severe generalized body pain for 1 day. She has been hospitalized for similar episodes in the past. Her medications include folic acid, hydroxyurea, and hydrocodone as needed for pain. After initial evaluation, including pertinent laboratory studies and chest x-ray, she is started on 1/2 normal saline at 125 mL/hr and hydromorphone every 3 hours. Over the next 36 hours, the patient complains of worsening chest pain and mild shortness of breath. Her temperature is 38.9 C (102 F), pulse is 112/min, and respirations are 23/min. Oxygen saturation is 93% on 2 L O₂. Lung examination shows bilateral crackles. Lower-extremity examination shows tenderness with palpation. Laboratory results are as follows: She has good urine output. Her chest x-ray on admission (Image 1) and repeat x-ray after 36 hours (Image 2) are shown below. Which of the following, if instituted on initial presentation, may have helped prevent the clinical worsening that occurred in this patient?

Accepted Answer

This patient, who initially presented with sickle cell pain crisis, now has symptoms suggestive of acute chest syndrome (ACS). ACS is defined as a new infiltrate on chest x-ray plus any of the following: fever; chest pain; or respiratory symptoms such as cough, wheezing, decreased oxygen saturation, tachypnea, or accessory respiratory muscle usage. Important etiologies for ACS are infection, asthma, hypoventilation, and pulmonary vasoocclusion from fat emboli. Negative chest x-rays obtained during initial presentation do not rule out subsequent development of ACS. ACS usually occurs within 48-72 hours of admission for pain crisis. Patients admitted for sickle crisis should be considered to be in the prodromal phases of ACS. Prophylactic measures such as close pulmonary monitoring, cautious hydration, optimal pain control, and incentive spirometry remain essential components of therapy. Treatment of ACS is based on severity. Simple transfusion for mild ACS and exchange transfusion for moderate-to-severe ACS are recommended with a target Hb of 10 g/dL. ACS and pneumonia are difficult to differentiate from each another. Therefore, empiric antibiotics that include coverage for atypical organisms (eg, Chlamydia and Mycoplasma) must be administered. However, prophylactic use of antibiotics to prevent ACS is not recommended (Choice A). Hydroxyurea should also be started for all patients with a history of ACS or at risk of developing it (eg, HbSS). (Choice B) A PCA pump may be helpful for better management of pain, but it does not help prevent ACS. Over-sedation can cause hypoventilation and should be avoided. (Choice D) Routine use of bronchodilators without evidence of asthma/wheezing has not been found useful in preventing ACS. (Choice E) Hypotonic fluids (1/2 normal saline or D51/2 normal saline) are recommended for acute sickle cell crisis. Adequate intravenous fluids are important to reduce sickling, but excess use for prolonged periods can cause pulmonary edema. This patient had received 125 mL/hr for 36 hours with good urine output, which should not lead to pulmonary edema. Educational objective: Incentive spirometry has been shown to reduce the likelihood of developing acute chest syndrome and should be encouraged in all patients presenting with sickle cell pain crisis. Similarly, hydroxyurea should be started in all patients with a history of acute chest syndrome or risk of developing it (eg, HbSS). __________ References: The use of incentive spirometry in pediatric patients with sickle cell disease to reduce the incidence of acute chest syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/21792036) Pulmonary complications of sickle cell disease. (http://www.ncbi.nlm.nih.gov/pubmed/21973051)

Question 20

A 19-year-old man comes to the emergency department with penile pain.  He started to get an erection about 2 hours ago, and it has not subsided.  He took pain medications without relief.  The patient has had no manipulation or trauma to his genitourinary tract.  His only medical problem is sickle cell disease (Hb SS), with his usual vasoocclusive crisis being joint and bone pain.  His last pain crisis was about 4 months ago.  His medications include hydroxyurea, folate, oxycodone, and acetaminophen.
His temperature is 37.8 C (100 F), blood pressure is 140/90 mm Hg, pulse is 120/min, and respirations are 32/min.  Pulse oximetry is 95% on room air.  Examination shows a very uncomfortable man with an erect penis.
Laboratory results are as follows:

His chest x-ray shows no infiltrates.
Which of the following is the most appropriate next step in management?

Accepted Answer

This patient with sickle cell disease (SCD) presents with priapism, a serious SCD complication defined as persistent (>2-4 hours) penile or clitoral erection not associated with sexual stimulation or desire. Priapism has a prevalence of up to 45% in SCD patients, with the first episode usually occurring before age 20. The erection may last >2 hours and is likely due to decreased oxygen levels in the corpora cavernosa, which lead to sickling and blockage of penile venous outflow. Irreversible ischemic changes may occur in the penile tissue if the priapism is not corrected after 4 hours, resulting in fibrosis and erectile dysfunction. Recurrent priapism with more frequent and longer episodes may also lead to similar changes. Priapism with milder symptoms lasting <2 hours usually responds to increased fluid intake, oral analgesics, and attempted urination once the erection subsides. Priapism lasting >2 hours with more significant symptoms requires intravenous pain medication and hydration, blood aspiration from the corpus cavernosum with saline irrigation, and intracavernosal injection of sympathomimetics (eg, phenylephrine, epinephrine) to restore penile venous outflow. This procedure is usually done by an urologist. Persistent priapism (>12 hours) may require surgical shunting (glans-spongiosum shunt) to bypass blood from the corpus cavernosum to the corpus spongiosum and relieve the occlusion (Choice E). (Choice B) Epidural pain control can be used if oral and intravenous pain medications have not provided relief. (Choice C) Exchange transfusions are controversial as they can rapidly increase the hemoglobin (Hgb) level. If exchange transfusion is used, the target goal of Hgb should be <10 g/dL. Higher target Hgb after exchange transfusion has been associated with neurologic complications (eg, headaches, seizures, obtundation requiring ventilatory support). Aspiration is recommended as first line treatment. (Choice D) Hydroxyurea has been used to prevent priapism but is not effective for acute treatment. Educational objective: Priapism is a serious complication associated with sickle cell disease and defined as an erection lasting >2-4 hours. Blood aspiration from the corpus cavernosum, followed by saline irrigation and use of adrenergic agonists (eg, epinephrine), is first-line therapy. If priapism still persists, surgical shunting may be required. __________ References: Priapism: a review. (http://www.ncbi.nlm.nih.gov/pubmed/11665875) Priapism in sickle cell disease. (http://www.ncbi.nlm.nih.gov/pubmed/16214652) Priapism in sickle cell disease: incidence, risk factors and complications -an international multicentre study. (http://www.ncbi.nlm.nih.gov/pubmed/12460353)

Exam 1: Emergency Department