quizzER Vol 2 Final Standings!

Congratulations to PRN PENGUIN - the first winner of quizzER.
PRN PENGUIN will receive a copy of PreTest Emergency Medicine

Check out PRN PENGUIN'S BLOG

The results were close, but PRN Penguin swept the competition by getting 8 out of 8 questions correct.

quizzER Top 10

1. prn pneguin (8/8)
   
2. NPG (6/8)
   
3. Rune (6/8)
   
4. WongML (6/8)
   
5. T-Dude (5/8)
   
6. Arkiem (4/8)
   
7. AmiB (3/8)
8. PTK (3/8)
9. HicksterAZ (2/8)
10. Nurse K (2/8)
    

Thank you to everyone who participated.
Don't forget to give this week's VizD a try.
Make sure you return next week for the start of the third volume of quizzER!

quizzER is a weekly contest consisting of a question selected from various areas of emergency medicine that are central to the education of medical students and residents in training. For more information please refer to the following link.

Vol 2:8 Answer

The Question
The answer is d.
The patient has an avulsed tooth, which is a dental emergency. When a tooth is missing from a patient, the possibility of aspiration or entrapment in soft tissues should be considered. Avulsed permanent teeth require prompt intervention. The best environment for an avulsed tooth is its socket. Replantation is most successful if the tooth is returned to its socket within 30 minutes of the avulsion. A 1% chance of successful replantation is lost for every minute that the tooth is outside of its socket. The tooth should only be handled by the crown as not to disrupt the root. If the patient cannot replant the tooth, then they should keep the tooth under his or her tongue or in the buccal pouch so that it is bathed in saliva. If that cannot be achieved, then the tooth can be placed in a cup of milk (e) or in saline. The best transport solution is Hank’s solution.

(a) The worst situation is to transport the tooth in a dry medium. (b) and (c) water and beer are less than ideal. Saliva, milk or saline are better solutions.


quizzER is a weekly contest consisting of a question selected from various areas of emergency medicine that are central to the education of medical students and residents in training. For more information please refer to the following link.

Vol 2:8 Question

Trauma
A 22-year-old man calls the ED from a local bar stating that he was punched in the face ten minutes ago and is holding his front incisor tooth in his hand. He wants to know what the best way to preserve the tooth is. Which of the following is the most appropriate advice to give the caller?
a. Place the tooth in a napkin and bring it to the Emergency Department
b. Place the tooth in a glass of water and bring it to the Emergency Department
c. Place the tooth in a glass of beer and bring it to the Emergency Department
d. Pour some water over the tooth and place it immediately back into the socket
e. Place the tooth in a glass of milk and bring it to the Emergency Department

Last question of the set before the winner is announced!

Please submit your answer in the "comment" section. The person with the most correct entries at the end of six weeks will receive a copy of the book PreTest Emergency Medicine.

For more information about the contest, please click here.

quizzER is a weekly contest consisting of a question selected from various areas of emergency medicine that are central to the education of medical students and residents in training. For more information please refer to the following link.

Vol 2:7 Answer

The Question
The answer is a.
γ-hydroxybutyrate (GHB) is a natural neurotransmitter that induces sleep. GHB has been sold as a muscle builder (release of growth hormone), a diet aid, and a sleep aid. Patients with GHB overdose generally have a decreased level of consciousness. In contrast to other sedative/hypnotic overdoses, the level of consciousness tends to fluctuate quickly between agitation and depression. A distinctive feature of GHB intoxication is respiratory depression with apnea, interrupted by periods of agitation and combativeness, especially following attempts at intubation.

(b) Diazepam, a benzodiazepine, also depresses mental and respiratory function but typically patients remain sedate. (c) Cocaine is a stimulant that increases heart rate, blood pressure, and usually causes the pupils to dilate. (d) PCP intoxication may cause bizarre behavior, lethargy, agitation, confusion, or violence. (e) Heroin intoxication can cause respiratory depression. Patients usually present with miotic pupils.

quizzER is a weekly contest consisting of a question selected from various areas of emergency medicine that are central to the education of medical students and residents in training. For more information please refer to the following link.

Vol 2:7 Question

Toxicology
A 19-year-old man is brought to the ED by EMS after he was found lying on the floor at a dance club. EMS states that the patient seemed unconscious at the dance club but as soon as they transferred him onto the gurney he became combative. Upon arrival in the ED, his blood pressure is 120/65 mm Hg, heart rate is 75 beats per minute, temperature is 98.9°F, respiratory rate is 12 breaths per minute, and oxygen saturation is 98% on room air. On physical exam, his pupils are mid-sized, equal and reactive to light. His skin is warm and dry. Lung, cardiac, and abdominal exam are unremarkable. As you walk away from the bedside, you here the monitor alarm signaling zero respirations and the oxygen saturation starts to drop. You perform a sternal rub and the patient sits up in bed and starts yelling at you. As you leave him for the second time, you hear the monitor alarm again signal zero respirations. You administer naloxone, but there is no change in his condition. Which of the following is most likely the substance ingested by this patient?
a. γ-hydroxybutyrate (GHB)
b. Diazepam
c. Cocaine
d. Phencyclidine (PCP)
e. Heroin

Please submit your answer in the "comment" section. The person with the most correct entries at the end of six weeks will receive a copy of the book PreTest Emergency Medicine.

For more information about the contest, please click here.

quizzER is a weekly contest consisting of a question selected from various areas of emergency medicine that are central to the education of medical students and residents in training. For more information please refer to the following link.

Vol 2:6 Answer

The Question
The answer is d
Myxedema coma is a life-threatening complication of hypothyroidism. Mortality in myxedema coma approaches 20% to 50% even with appropriate management. The patient exhibits classic signs and symptoms of the disease: lethargy or coma, hypothermia, bradycardia, periorbital and nonpitting edema and delayed relaxation phase of deep tendon reflexes (areflexia in more severe cases). Myxedema coma can be triggered by sepsis, trauma, surgery, congestive heart failure, prolonged cold exposure or use of sedatives or narcotics.

(a) The patient is actually hyperglycemic. Abnormal reflexes, hypothermia and periorbital edema are inconsistent with the diagnosis of hypoglycemia as well as that of myocardial infarction (b). Stroke (c) should be on the differential in this case but the patient’s signs and symptoms are more consistent with abnormal metabolic state than with purely neurovascular change. Depression (e) is an often forgotten diagnosis in the elderly and may present with a wide variety of signs and symptoms. Severe depression may appear as lethargy. It is unlikely, however, to have associated hypothermia and abnormal reflexes.

Don't forget to give this week's VizD a try.

quizzER is a weekly contest consisting of a question selected from various areas of emergency medicine that are central to the education of medical students and residents in training. For more information please refer to the following link.

Vol 2:6 Question

Altered Mental Status
A 74-year-old lethargic woman is brought to the ED by her family. Her daughter states that the patient has been progressively somnolent over the last week and could not be woken up today. The patient takes medications for diabetes, hypertension, hypothyroidism and a recent ankle sprain, which is treated with a hydrocodone/acetaminophen combination. In the ED, the patient is profoundly lethargic, responsive only to pain, and has periorbital edema and delayed relaxation of the deep tendon reflexes. Her blood pressure is 145/84 mm Hg, heart rate is 56 beats per minute, temperature is 94.8°F, and respiratory rate is 12 breaths per minute. Her fingerstick glucose is 195 mg/dL. Which of the following is the most likely diagnosis?
a. Hypoglycemia
b. Myocardial infarction
c. Stroke
d. Myxedema coma
e. Depression

Please submit your answer in the "comment" section. The person with the most correct entries at the end of six weeks will receive a copy of the book PreTest Emergency Medicine.

For more information about the contest, please click here.

quizzER is a weekly contest consisting of a question selected from various areas of emergency medicine that are central to the education of medical students and residents in training. For more information please refer to the following link.

Vol 2:5 Answer

The Question
The answer is c.
This patient is in cardiogenic shock from decreased cardiac output producing inadequate tissue perfusion. Support for this diagnosis includes an older patient with a history of coronary artery disease, with new mental status changes coupled with signs of volume overload. Common causes of cardiogenic shock include acute myocardial infarction, pulmonary embolism, COPD exacerbation, and pneumonia. This patient should be stabilized with intravenous pressors since there is already pulmonary congestion evident on exam. A rapid workup including ECG, CXR, laboratory tests, echocardiogram, and hemodynamic monitoring should help confirm the etiology and direct specific treatment of the underlying cause.

Hypovolemic shock (a) occurs when there is inadequate volume in the circulatory system, resulting in poor oxygen delivery to the tissues. Neurogenic shock (b) occurs after an acute spinal cord injury, which disrupts sympathetic innervation resulting in hypotension and bradycardia. Anaphylactic shock (d) is a severe systemic hypersensitivity reaction resulting in hypotension and airway compromise. Septic shock (e) is a clinical syndrome of hypoperfusion and multi-organ dysfunction caused by infection.

Don't forget to give this week's VizD a try.

quizzER is a weekly contest consisting of a question selected from various areas of emergency medicine that are central to the education of medical students and residents in training. For more information please refer to the following link.

Vol 2:5 Question

Shock
A 79-year-old woman with a history of coronary artery disease who underwent a coronary artery bypass graft surgery in 2000 is brought to the ED by her family for two days of worsening shortness of breath. For the past 2 days, she has not gotten out of bed and is confused. She does not have chest pain, fevers, or cough. Her temperature is 98.1°F, blood pressure is 85/50 mm Hg, heart rate is 125 beats per minute, and respiratory rate is 26 breaths per minute. On exam, she is unable to follow commands and is oriented only to name. The cardiovascular exam reveals tachycardia with no murmurs. Her lungs have rales bilaterally at the bases. The abdomen is soft, nontender, and nondistended. Lower extremities have 2+ edema to the knee bilaterally. Which of the following is the most likely diagnosis?
a. Hypovolemic shock
b. Neurogenic shock
c. Cardiogenic shock
d. Anaphylactic shock
e. Septic shock

Please submit your answer in the "comment" section. The person with the most correct entries at the end of six weeks will receive a copy of the book PreTest Emergency Medicine.

For more information about the contest, please click here.

quizzER is a weekly contest consisting of a question selected from various areas of emergency medicine that are central to the education of medical students and residents in training. For more information please refer to the following link.

Vol 2:4 Answer

The Question
The answer is c.
The patient most likely sustained a corneal abrasion from prolonged contact lens use. Epithelial defects of the cornea are diagnosed by slit lamp exam by observing fluorescein uptake in the area of the defect. Treatment usually consists of cycloplegia, and topical or oral pain medications. Contact lens patients should be treated with topical antibiotics with antipseudomonal coverage. Patients should not wear their contact lens until complete healing of the corneal epithelium. All patients should follow-up with an ophthalmologist.

(a) Corneal abrasions usually heal well with appropriate care and do not require a transplant. (d) Amoxicillin is not an appropriate antibiotic because it is not topical and not anti-pseudomonal. In addition, tetracaine, if used frequently, can decompose the cornea and cause permanent damage. (e) Eye patching should be avoided, particularly with injuries involving contact lens. Data suggest that eye patching confers no benefit in healing small, uncomplicated corneal abrasions and may provide a better environment for pseudomonas to proliferate.

Don't forget to give this week's VizD a try.

quizzER is a weekly contest consisting of a question selected from various areas of emergency medicine that are central to the education of medical students and residents in training. For more information please refer to the following link.

Vol 2:4 Question

Eye Pain
A 24-year-old woman presents to the ED complaining of right eye pain and blurry vision since waking up this morning. She states that the pain began after taking out contact lens that were in her eyes for over one week. Her blood pressure is 120/75 mm Hg, heart rate is 75 beats per minute, temperature is 99.1°F, and respiratory rate is 16 breaths per minute. Her right and left eye visual acuity is 20/60 and 20/20, respectively. Her conjunctivae are injected. The slit lamp exam reveals a large area of fluorescein uptake over the visual axis. Which of the following is the most appropriate therapy?

a. Call the ophthalmology consult for an emergent corneal transplant

b. Prescribe a systemic analgesic for pain control and advise the patient to not wear her contact lenses for the next week

c. Prescribe ciprofloxacin eye drops, oral analgesia, update tetanus prophylaxis, and arrange for ophthalmology follow up

d. Prescribe oral amoxicillin, a topical anesthetic such as tetracaine and have patient follow up with an ophthalmologist

e. Prescribe ciprofloxacin eye drops and have patient strictly wear an eye patch until her pain resolves

Please submit your answer in the "comment" section. The person with the most correct entries at the end of six weeks will receive a copy of the book PreTest Emergency Medicine.

For more information about the contest, please click here.

quizzER is a weekly contest consisting of a question selected from various areas of emergency medicine that are central to the education of medical students and residents in training. For more information please refer to the following link.

Vol 2:3 Answer

The Question

The answer is c

This patient sustained an injury from a venomous marine animal. Approximately 50,000 such incidents occur yearly. Marine animals may be divided into two classes: stingers and nematocysts. Stingers include sea urchins, stingrays, catfish, cone shells, and starfish. Radiographs may be useful in delineating the calciferous material deposited in the skin for removal. Nematocysts are much more prevalent and account for the majority of envenomations and most likely account for this patient’s distress. This class includes jellyfish, fire corals, Portuguese man-o-war, and anemones. These creatures have spring-loaded venomous glands that discharge upon mechanical or chemical stimulation. The number of nematocysts on a tentacle can number in the thousands. These stinging cells can remain activated after weeks of the animal being beached. The venom contains various peptides and enzymes that may cause progression of symptoms including nausea, muscle cramps, dyspnea, angioedema, and anaphylaxis. The preferred treatment is vinegar, which deactivates the nematocyst. In cases where medical attention cannot be sought in a timely manner, urine has been shown to be just as efficacious. An attempt may be made to shave off nematocysts after proper analgesia. Patient should be given tetanus prophylaxis and anti-histamines as needed.

(a) Fresh water activates the nematocyst and should be avoided. (b, d, and e) Vegetable oil, toothpaste, and household window cleaners should also be avoided as they might cause further irritation and pain.

Don't forget to give this week's VizD a try.

quizzER is a weekly contest consisting of a question selected from various areas of emergency medicine that are central to the education of medical students and residents in training. For more information please refer to the following link.

Vol 2:3 Question

Environmental
An 18-year-old man presents to the Emergency Department with right leg pain and swelling after swimming at a local beach. He reports swimming in the ocean, whereupon he felt a sharp sting in his right leg. Upon physical examination, there is no gross deformity of the right lower extremity and there is a palpable dorsalis pedis and posterior tibial pulse. There is tenderness to palpation over the lateral calf where many punctuate, erythematous lesions as seen below. You suspect he was stung by a jellyfish. Which of the following is the most appropriate treatment of choice for this patient?
a. Fresh water
b. Vegetable oil
c. Vinegar
d. Toothpaste
e. Household window cleaner

Please submit your answer in the "comment" section. The person with the most correct entries at the end of six weeks will receive a copy of the book PreTest Emergency Medicine.

For more information about the contest, please click here.

quizzER is a weekly contest consisting of a question selected from various areas of emergency medicine that are central to the education of medical students and residents in training. For more information please refer to the following link.

Vol 2:2 Answer

Thank you to everyone who participated.

The Question

The answer is a.

Emergency Medicine always starts with an assessment of the patient’s airway. For patients suspected of having a significant GI bleed, two large-bore IV lines need to be established rapidly. Treating an undifferentiated upper GI bleed is like treating a gun shot wound to the abdomen—you should expect the worse. Immediate volume resuscitation should begin with 1-2 liters of normal saline. If there is no improvement in the blood pressure of a hypotensive patient, then blood should be administered. Sending a crossmatch early is advisable since it can take up to an hour to retrieve.

(b) A proton-pump inhibitor may be administered but priority is to the ABCs and this patient is hypotensive. (c) You must assess airway first. (d) and (e) The patient is maintaining his airway and does not need to be intubated emergently.


Don't forget to give this week's VizD a try.

quizzER is a weekly contest consisting of a question selected from various areas of emergency medicine that are central to the education of medical students and residents in training. For more information please refer to the following link.

Vol 2:2 Question

GI Bleed
A 51-year-old man is brought to the ED by EMS with a BP 90/60 mmHg, HR 110 beats per minute, RR 18 breaths per minute, and oxygen saturation of 97% on room air. The patient tells you that he has a history of bleeding ulcers. On exam, his abdomen is tender in the epigastric area. He is guaiac positive with black stool. He has a bout of hematemesis and you notice that his blood pressure is now 80/50 mm Hg, HR is 114 beats per minute, and the patient is starting to drift off. Which of the following is the most appropriate next step in therapy?

a. Assess airway, establish two large-bore IVs, cross-match for two units of blood, administer 1-2 liters of normal saline, and schedule an emergent endoscopy

b. Assess airway, establish two large-bore IVs, crossmatch for two units of blood, and administer a proton pump inhibitor

c. Place two large-bore IVs, crossmatch for two units of blood, administer a 1-2 liters of normal saline, and schedule an emergent endoscopy

d. Intubate the patient, establish two large-bore IVs, cross-match for two units of blood, administer a 1-2 liters of normal saline, and schedule an emergent endoscopy

e. Intubate the patient, establish two large-bore IVs, crossmatch for two units of blood, and administer a proton pump inhibitor

Please submit your answer in the "comment" section. The person with the most correct entries at the end of six weeks will receive a copy of the book PreTest Emergency Medicine.

For more information about the contest, please click here.

quizzER is a weekly contest consisting of a question selected from various areas of emergency medicine that are central to the education of medical students and residents in training. For more information please refer to the following link.

Vol 2:1 Answer

Thank you to everyone who participated.

The Question

The answer is a.
This patient presents with symptoms consistent with meningitis. Antibiotics are administered empirically as diagnostic workup proceeds. The best choice in this patient is ceftriaxone, which has good CNS penetration. In order to avoid transtentorial herniation in this patient with a neurologic deficit (confusion), a non-contrast head CT should be performed prior to LP. It is controversial whether or not a head CT needs to be performed prior to all LPs. However, if there is papilledema or a neurologic deficit, then head CT is mandatory.

(b) It is not prudent to wait for results from a head CT. This will only delay treatment of a potentially fatal disease. (c) Although this patient can benefit from acetaminophen and hydration, starting antibiotics empirically is more important. In addition, this patient requires a head CT prior to LP. (d & e) As previously stated, antibiotics should be started early in management and not be delayed while waiting for results.

Don't forget to give this week's VizD a try.

quizzER is a weekly contest consisting of a question selected from various areas of emergency medicine that are central to the education of medical students and residents in training. For more information please refer to the following link.

Vol 2:1 Question

You think your headache is bad...Give this week's quizzER a try!

Headache
A 21-year-old college student is brought by her roommate to the ED. The roommate states that earlier in the day the patient complained of a severe headache, stiff neck and photophobia. On their way to the ED, the roommate states that the patient was confused. Her vital signs are BP 110/80 mm Hg, HR 110 beats per minutes, RR 16 breaths per minute, and temperature 102°F. What is the next step in the management of this patient?
a. Start empiric antibiotics, non-contrast head CT prior to performing lumbar puncture
b. Order a non-contrast head CT and start antibiotics once the results are back
c. Give 1 gram of acetaminophen, start fluid hydration and perform a lumbar puncture
d. Perform a lumbar puncture and start antibiotics once the results are back
e. Order a non-contrast head CT, perform LP, then start antibiotics

Please submit your answer in the "comment" section. The person with the most correct entries at the end of the month will receive a copy of the book PreTest Emergency Medicine.

For more information about the contest, please click here.

quizzER is a weekly contest consisting of a question selected from various areas of emergency medicine that are central to the education of medical students and residents in training. For more information please refer to the following link.

Vol 1:4 Answer

Congratulations to Andaleeb - the first winner of quizzER.
Andaleeb will receive a copy of PreTest Emergency Medicine

The results were close with 4 participants getting all 4 questions correct (winner selected randomly from 4 winners)

quizzER Top 10

1. Andaleeb (4/4)
   
2. Carola (4/4)
   
3. HicksterAZ (4/4)
   
4. Joshua (4/4)
   
5. Cody (3/4)
   
6. Rune (3/4)
   
7. Npg (3/4)
8. Nurse K (2/4)
9. Helen (2/4)
10. Wongml (2/4)
    

Thank you to everyone who participated.
Don't forget to give this week's VizD a try.

The Question Vol 1:4

The answer is c.
Spearing generates an axial loading force that is transmitted through the occipital condyles to the superior articular surfaces of the lateral masses of the first cervical vertebra (C-1). This fracture is commonly referred to as a Jefferson fracture. It is considered an unstable fracture; however, it is not commonly associated with spinal cord injury due to the increased area of the C-1 foramen. It is associated with diving accidents and in this scenario, “spearing” in a football game, which places an increased axial load to the cervical spine. Proper cervical spine precautions should remain in place throughout his management in the ED.

quizzER is a weekly contest consisting of a question selected from various areas of emergency medicine that are central to the education of medical students and residents in training. For more information please refer to the following link.

Vol 1:4 Question

Trauma
A 17-year-old high school football player is brought to the ED by paramedics on a backboard and cervical collar. During a football game, the patient “speared” another player with his helmet and subsequently experienced severe neck pain. He denies paresthesias and is able to move all of his extremities. A cervical spine CT scan reveals multiple fractures of the first cervical vertebra. Which of the following best describes this fracture?
a. Odontoid fracture
b. Hangman fracture
c. Jefferson fracture
d. Clay-Shoveler’s fracture
e. Teardrop fracture


Please submit your answer in the "comment" section. The person with the most correct entries at the end of the month will receive a copy of the book PreTest Emergency Medicine.

For more information about the contest, please click here.

quizzER is a weekly contest consisting of a question selected from various areas of emergency medicine that are central to the education of medical students and residents in training. For more information please refer to the following link.

Vol 1:3 Answer

Thank you to everyone who participated. Your answers were recorded. Don't forget to give this week's VizD a try.

The Question

The answer is c.
Spinal abscesses are most commonly found in immunocompromised patients, IV drug users, and the elderly. Signs and symptoms of epidural abscess usually develop over a week or two and include fever, localized pain, and progressive weakness. An elevated WBC count is also commonly seen. MRI is the most useful diagnostic test. Staphylococcus aureus is the most common causative organism, followed by gram-negative bacilli and tuberculosis bacillus.

quizzER is a weekly contest consisting of a question selected from various areas of emergency medicine that are central to the education of medical students and residents in training. For more information please refer to the following link.