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A 55-year-old Caucasian female presents to your office and complains of early satiety, nausea, bloating and
occasional vomiting. She w as diagnosed w ith diabetes mellitus 20 years ago, and is currently being treated
w ith insulin. She has no know n allergies. She does not smoke or consume alcohol, and denies any
recreational drug use. Her most recent HbA1c value is 9.8%. After running a couple of tests, you prescribe
low volume, frequent meals, and oral metoclopramide. The patient returns the next day w ith deviation of the
head and eyes, and involuntary tongue movements. She seems scared. W hat is the best next step in the
management of this patient?

r A. Propranolol IV
r B. Dantrolene, orally
r C. Diazepam IV
r D. Haloperidol IV
r E. Diphenhydramine IV

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A 55-year-old Caucasian female presents to your office and complains of early satiety, nausea, bloating and
occasional vomiting. She w as diagnosed w ith diabetes mellitus 20 years ago, and is currently being treated
w ith insulin. She has no know n allergies. She does not smoke or consume alcohol, and denies any
recreational drug use. Her most recent HbA1c value is 9.8%. After running a couple of tests, you prescribe
low volume, frequent meals, and oral metoclopramide. The patient returns the next day w ith deviation of the
head and eyes, and involuntary tongue movements. She seems scared. W hat is the best next step in the
management of this patient?

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A. Propranolol IV [3%1
B. Dantrolene, orally [1 7%1
C. Diazepam IV [12%1
D. Haloperidol IV [7%1

E. Diphenhydramine IV [60%1

Explanation:

User ld:

This patient is experiencing acute dystonic reaction related to metoclopramide use. Extrapyramidal
symptoms are uncommon if low doses of metoclopramide are used, but their incidence may exceed 30% if
high doses are consumed. These usually occur w ithin 24-48 hours after the initiation of therapy.
Diphenhydramine IV is the drug of choice for the immediate treatment of metoclopramide-induced acute
dystonia because aside from its antihistamine properties, it has anticholinergic properties, and is usually w ell
tolerated. Diphenhydramine IV typically provides quick relief (w ithin 3-5 minutes after administration). If
dystonic reactions are not responsive to diphenhydramine, benztropine IV is usually used.

(Choice B) Dantrolene is a peripheral muscle relaxant, but it is not used in such cases.
(Choice C) Diazepam has no anticholinergic properties. It cannot act as an effective antidote.
(Choice D) Haloperidol can aggravate the condition and should not be used.
Educational Objective:
Diphenhydramine IV is the drug of choice for the immediate treatment of metoclopramide-induced acute
dvstonia.

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A 3-year-old Caucasian boy is brought to your office by his mother w ith complaints of irritability and decreased
appetite. The mother says that the boy seems w eak and has been less active over the last several w eeks.
The patient regularly spends some time outside the house under the supervision of his older brother, and the
brother saw him eating cement and w oodwork several times. The patient's past medical history is
insignificant. He has no know n allergies. All his vaccinations are up-to-date. He received iron and vitamin D
supplements. His vital signs are stable. Physical examination reveals a non-distended abdomen w ith
periumbilical tenderness. W hat is the best next step in the management of this patient?

r A. Urinalysis
r B. Complete blood count
r C. Basic metabolic profile
r D. Upper Gl series
r E. Serum folate level

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.j-year-010 t.-aucas1an ooy IS orougm to your omce oy ms momer w nn comp1a1ms or 1rmaomty ana aecreasea
appetite. The mother says that the boy seems w eak and has been less active over the last several w eeks.
The patient regularly spends some time outside the house under the supervision of his older brother, and the
brother saw him eating cement and w oodwork several times. The patient's past medical history is
insignificant. He has no know n allergies. All his vaccinations are up-to-date. He received iron and vitamin D
supplements. His vital signs are stable. Physical examination reveals a non-distended abdomen w ith
periumbilical tenderness. W hat is the best next step in the management of this patient?

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A. Urinalysis [2%1
B. Complete blood count [70%1
C. Basic metabolic profile [8%1
D. Upper Gl series [1 6%1

E. Serum folate level [4%1

Explanation:

User ld:

Although the lead concentration in the environment has been decreased recently, it still remains a significant
environmental hazard. Children are especially susceptible because of their typical 'hand-mouth' behavior.
The prompt recognition of lead poisoning is very important because some complications (mainly neurological
and neurocognitive) can be irreversible. Many patients present w ith non-specific symptoms such as anorexia,
decreased activity, irritability, vague abdominal pain and insomnia; therefore, careful history taking (living
conditions, potential environmental exposures, and 'hand-mouth' behavior) and a high degree of suspicion are
important for early diagnosis. The initial laboratory evaluation in patients w ith suspected lead poisoning should
include CBC, serum iron and ferritin levels, and reticulocyte count. These tests w ill help detect the presence
of anemia and iron deficiency. Measuring blood lead levels is crucial for the development of the treatment
plan .

(Choices C and A) In patients w ho require chelation therapy, a basic metabolic profile and urinalysis should
be performed.
(Choice D) Abdominal radiographs may be indicated in patients w ith a history of acute ingestion of lead
containing products (e.g., fishing w eights).
Educational Objective:
The initial laboratory evaluation in patients w ith suspected lead poisoning should include CBC, serum iron and
ferritin levels, and reticulocyte count. These tests w ill help detect the presence of anemia and iron deficiency.

!II PMark

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A 62-year-old man is hospitalized for a coronary artery bypass graft and aortic valve replacement. His other
medical problems include myocardial infarction, hypertension, hyperlipidemia, chronic back pain, and mild
chronic kidney disease. The patient is a retired financial advisor with a 50-pack-year smoking history. He
underwent the surgery without complications and w as successfully extubated the next day. His postoperative
medications include atorvastatin, metoprolol, morphine, and vancomycin. On the third postoperative day, the
patient is found to be progressively drow sy, lethargic, and difficult to rouse. His temperature is 36.1 C (97 F),
blood pressure is 102/63 mm Hg, heart rate is 112/min and irregularly irregular, and respirations are 10/min.
His pulse oximetry is 99% on 100% non-rebreather mask. Examination show s minimal crackles at lung
bases. The pupils are 3 mm and equal. The patient withdraws all extremities equally to pain .
Electrocardiogram show s atrial fibrillation with rapid ventricular response. His fingerstick glucose level is 125
mg/dl. Laboratory results are as follow s:
Leukocytes
Potassium
Creatinine

9,500/IJL
4.2 mEq/L
3. 1 mg/dL

Which of the following is the most likely cause of his mental status changes?

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A. Adverse effects of medication


B. Bypass graft closure
C. Ischemic stroke
D. Uncontrolled arrhythmia

E. Uremic toxins

if

Lab Values

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Lab Values

A 62-year-old man is hospitalized for a coronary artery bypass graft and aortic valve replacement. His other
medical problems include myocardial infarction, hypertension, hyperlipidemia, chronic back pain, and mild
chronic kidney disease. The patient is a retired financial advisor with a 50-pack-year smoking history. He
underwent the surgery without complications and w as successfully extubated the next day. His postoperative
medications include atorvastatin, metoprolol, morphine, and vancomycin. On the third postoperative day, the
patient is found to be progressively drow sy, lethargic, and difficult to rouse. His temperature is 36.1 C (97 F),
blood pressure is 102/63 mm Hg, heart rate is 112/min and irregularly irregular, and respirations are 10/min.
His pulse oximetry is 99% on 100% non-rebreather mask. Examination show s minimal crackles at lung
bases. The pupils are 3 mm and equal. The patient withdraws all extremities equally to pain .
Electrocardiogram show s atrial fibrillation with rapid ventricular response. His fingerstick glucose level is 125
mg/dl. Laboratory results are as follow s:
Leukocytes
Potassium
Creatinine

9,500/IJL
4.2 mEq/L
3. 1 mg/dL

Which of the following is the most likely cause of his mental status changes?

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A. Adverse effects of medication [27%]


B. Bypass graft closure [7%]
C. Ischemic stroke [0%]
D. Uncontrolled arrhythmia [1 3%]

E. Uremic toxins [53%]

User ld:

Explanation:

Clinical features of acute opioid intoxication


Decreased mental status
Miosis

Notes

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Clinical features of acute opioid intoxication

Signs &
symptoms

Decreased mental status


Miosis
Decreased respiratory rate & shallow breaths
Bradycardia
Decreased bowel sounds
Hypothermia (or normothermia)

Workup

Arterial blood gas (respiratory acidosis)


Fingerstick blood glucose (hypoglycemia)
Evaluate for presence of other drugs (eg, acetaminophen)
ECG for prolonged QTc with methadone overdose

Treatment

Naloxone, may need repeated doses


Airway management & ventilation
Consider continuous cardiac monitoring (if QTc >500 msec)

USMLEWorld. LLC

This patient has the clinical triad of depressed respiratory rate (< 10/min) w ith shallow breaths (crackles from
basal atelectasis), small pupils, and drow siness consistent w ith acute opioid toxicity. Decreased bow el
sounds are also common. Morphine acts directly on brainstem respiratory centers to produce respiratory
depression that results in decreased depth and frequency of breaths (leading to respiratory acidosis). It also
decreases both the hypercapnic and hypoxic respiratory drive from interaction w ith central and peripheral
chemoreceptors.
Morphine undergoes a 2-step metabolic process, beginning w ith hepatic conjugation w ith glucuronic acid to
form the metabolites morphine-3-glucuronide and morphine-6-glucuronide (w hich is more potent than
morphine). The kidney then eliminates the metabolites. In the setting of kidney injury, morphine-6glucuronide accumulates and potentiates the effects of morphine; patients in the postoperative period are at
particular risk for this clinical scenario.

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Lab Values

decreases both the hypercapnic and hypoxic respiratory drive from interaction w ith central and peripheral
chemoreceptors.
Morphine undergoes a 2-step metabolic process, beginning w ith hepatic conjugation w ith glucuronic acid to
form the metabolites morphine-3-glucuronide and morphine-6-glucuronide {w hich is more potent than
morphine). The kidney then eliminates the metabolites. In the setting of kidney injury, morphine-6glucuronide accumulates and potentiates the effects of morphine; patients in the postoperative period are at
particular risk for this clinical scenario.

(Choice B) A bypass graft closure can occur w ithin 30 days after coronary artery bypass graft (CABG) and
presents w ith postoperative ischemia and possible hemodynamic instability. Electrocardiogram (ECG)
typically show s evidence of ischemia w ith ventricular arrhythmias. This patient appears hemodynamically
stable and is unlikely to have acute graft closure.
(Choice C) The lack of focal neurologic deficits in this patient makes postoperative ischemic stroke less
likely. He is moving all 4 extremities equally.
(Choice D) Atrial fibrillation occurs after CABG in 15%-40% of patients. It is usually self-limited in those
w ithout a prior history of atrial fibrillation and reverts to sinus rhythm 6-8 w eeks after surgery. This patient is
hemodynamically stable even though he has a fast ventricular response.
(Choice E) Uremia involves a buildup of toxins that can cause nausea, vomiting, neuropathy, lethargy,
seizures, and coma. Uremia is usually seen in the setting of end-stage renal disease. It is less likely in this
patient, w ho may have acute kidney injury (in addition to mild chronic kidney disease) caused by prerenal
azotemia or acute tubular necrosis.
Educational objective:
Opioid toxicity presents w ith the clinical triad of respiratory depression, miosis, and depressed mental
status. Decreased bow el sounds are also common. Opioids should be monitored and dosed appropriately
as their effects can be w orsened in the setting of renal injury or liver disease.
References:

1. Pharmacokinetics of opioids in renal dysfunction

Time Spent: 5 seconds

Copyright USMLEW orld,LLC.

l ast updated: [9/24/2014]

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The following vignette applies to the next 2 items


A 38-year-old Caucasian w oman is brought to the emergency department by her cow orkers, w ho noticed that
she had been "breathing heavily" and had been restless for the last couple of hours, w hen she started to
become drow sy. She complains of nausea, vomiting, dizziness and tinnitus; these have been present for the
past few hours. She denies shortness of breath, cough or chest pain . Her other medical problems include
rheumatoid arthritis and depression. She has smoked one pack of cigarettes daily for the past twenty years.
She uses marijuana occasionally and drinks one glass of beer daily. Her medications include aspirin,
fluoxetine and low -dose prednisone. She has no know n drug allergies. Her temperature is 38 C ( 100.4 F),
blood pressure is 120/80 mm Hg, pulse is 100/min, respirations are 26/min, and oxygen saturation is 99% at
room air. Examination reveals an awake, but mildly drow sy young w oman w ith dry mucus membranes.
Heart sounds are normal. Lungs are clear. The abdomen is soft, non-tender, and non-distended; bow el
sounds are present. There is no rebound tenderness or rigidity. No motor or sensory focal deficit is present.
Meningeal signs are absent. A 12-lead electrocardiogram (EKG) show s sinus tachycardia . A portable chest
x-ray reveals no abnormalities: the lung fields are clear; there is no cardiomegaly or effusions. The patient is
given intravenous fluids and 1-liter oxygen per nasal cannula . She is placed on continuous EKG monitoring.
Laboratory tests are ordered.

Item 1 of 2
W hich of the follow ing is the most likely cause of her condition?

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A. Anxiety
B. Diastolic heart failure
C. Pulmonary embolism
D. Drug overdose

E. Acute bacterial pneumonia

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The following vignette applies to the next 2 items


A 38-year-old Caucasian w oman is brought to the emergency department by her cow orkers, w ho noticed that
she had been "breathing heavily" and had been restless for the last couple of hours, w hen she started to
become drow sy. She complains of nausea, vomiting, dizziness and tinnitus; these have been present for the
past few hours. She denies shortness of breath, cough or chest pain . Her other medical problems include
rheumatoid arthritis and depression. She has smoked one pack of cigarettes daily for the past twenty years.
She uses marijuana occasionally and drinks one glass of beer daily. Her medications include aspirin,
fluoxetine and low -dose prednisone. She has no know n drug allergies. Her temperature is 38 C ( 100.4 F),
blood pressure is 120/80 mm Hg, pulse is 100/min, respirations are 26/min, and oxygen saturation is 99% at
room air. Examination reveals an awake, but mildly drow sy young w oman w ith dry mucus membranes.
Heart sounds are normal. Lungs are clear. The abdomen is soft, non-tender, and non-distended; bow el
sounds are present. There is no rebound tenderness or rigidity. No motor or sensory focal deficit is present.
Meningeal signs are absent. A 12-lead electrocardiogram (EKG) show s sinus tachycardia . A portable chest
x-ray reveals no abnormalities: the lung fields are clear; there is no cardiomegaly or effusions. The patient is
given intravenous fluids and 1-liter oxygen per nasal cannula . She is placed on continuous EKG monitoring.
Laboratory tests are ordered.
Item 1 of 2
W hich of the follow ing is the most likely cause of her condition?

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A. Anxiety [6%1
B. Diastolic heart failure [1 %1
C. Pulmonary embolism [5%1
D. Drug overdose [87%1

E. Acute bacterial pneumonia [1 %1

Explanation:

User ld:

The patient's symptoms, along w ith her history of illicit drug intake and aspirin use, highly suggest an
overdose of aspirin or another drug that causes metabolic acidosis. The initial manifestations of salicylate
intoxication are tinnitus, restlessness, nausea, vomiting, and mild gastrointestinal discomfort. After a few

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r C. Pulmonary embolism [5%]


., r D. Drug overdose [87%]
r E. Acute bacterial pneumonia [1 %]
Explanation:

User ld:

The patient's symptoms, along w ith her history of illicit drug intake and aspirin use, highly suggest an
overdose of aspirin or another drug that causes metabolic acidosis. The initial manifestations of salicylate
intoxication are tinnitus, restlessness, nausea, vomiting, and mild gastrointestinal discomfort. After a few
hours, a depressed level of consciousness w ill ensue. Fever, metabolic acidosis, and hyperventilation
eventually develop. Hyperventilation w ithout dyspnea is suggestive of respiratory alkalosis, w hich may be a
compensatory response to the metabolic acidosis. Aside from tachycardia and tachypnea, there are no other
indications of cardiac or pulmonary compromise.

(Choice B) Although diastolic dysfunction can be suspected in a patient w ith signs and symptoms of heart
failure w ith a normal ejection fraction, there is no clinical evidence of heart failure in this case.
(Choice C) Pulmonary embolism can present w ith sinus tachycardia, normal chest x-ray and mild fever;
how ever, this diagnosis cannot fully explain the patient's other presenting characteristics (i.e., oxygen
saturation is 99%, drow sy state w ithout being hypoxic, nausea, vomiting and tinnitus).
(Choice A) The presence of fever, drow siness, tachycardia and tachypnea, as w ell as the patient's denial of
dyspnea, points to an organic cause of her disease.
(Choice E) The patient does not have a history of cough, dyspnea or sputum production. The chest x-ray is
clear, and her oxygen desaturation is 99%. For these reasons, the possibility of pneumonia is very unlikely.
Educational Objective:
Dyspnea is the subjective sensation of labored or difficult breathing. Athletes and w ell-trained individuals
develop dyspnea only w hen doing hard w ork or exercise, w hile sedentary subjects may experience it even
after minor efforts. Hyperventilation associated w ith metabolic acidosis is hardly ever accompanied by
dyspnea . Metabolic acidosis must be suspected as the cause of hyperventilation (compensatory respiratory
alkalosis) w ithout dyspnea if there is no evidence of cardiac or pulmonary disease, the patient is a potential
drug abuser, and there are signs and symptoms compatible w ith compromise of other organs.
Time Spent: 30 seconds

Copyright USMLEW orld,LLC.

Last updated: [5/ 11/2014]

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Item 2 of 2
The patient continues to be drow sy, but she is now easily arousable. Her temperature is 37.8 C (100 F),
blood pressure is 120/70 mm Hg, pulse is 104/min, respirations are 28/min, and oxygen saturation is 100%
w ith one-liter nasal cannula . Her laboratory tests reveal the follow ing:
CBC
Hb
Ht
MCV
Platelet count
Leukocyte count
Segmented neutrophils
Bands
Eosinophils
Lymphocytes
Monocytes

13.8 g/dL
41 %

91fl
320,000/cmm
6,000/cmm
70%
2%
2%
18%
8%

Serum chemistry
Serum Na
Serum K
Chloride
Bicarbonate
BUN
Serum creatinine
Calcium
Blood glucose

145 mEq/L
4.3 mEq/L
108 mEq/L
17 mEq/L
30 mg/dL
1.6 mg/dL
9.9 mg/dL
75 mg/dL

Total bilirubin
Direct bilirubin
Alkaline phosphatase
Aspartate aminotransferase

1.3 mg/dL
0.8 mg/dL
200 U/L
150 U/L
110 l J/1

LFT

Al;minP. ;:~minotr;:~n!':fP.r<'I!':P.

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Monocytes

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Serum chemistry

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Serum Na
Serum K
Chloride
Bicarbonate
BUN
Serum creatinine
Calcium
Blood glucose

145 mEq/L
4.3 mEq/L
108 mEq/L
17 mEq/L
30 mg/dl
1.6 mg/dl
9.9 mg/dl
75 mg/dl

Total bilirubin
Direct bilirubin
Alkaline phosphatase
Aspartate aminotransferase
Alanine aminotransferase

1.3 mg/dl
0.8 mg/dl
200 U/L
150 U/L
11 0 U/L

LFT

Gases, arterial blood


pH
pC02
p02

7.25
20 mm Hg
11 0 mm Hg

Item 2 of 2
Which of the following is the most appropriate next step in management?

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A. Intravenous antibiotics
B. Oral lactulose and metronidazole
C. Intravenous furosemide
D. Non invasive mechanical ventilation

E. Alkaliniz ation of the urine

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Item 2 of 2
The patient continues to be drow sy, but she is now easily arousable. Her temperature is 37.8 C (100 F),
blood pressure is 120/70 mm Hg, pulse is 104/min, respirations are 28/min, and oxygen saturation is 100%
w ith one-liter nasal cannula. Her laboratory tests reveal the follow ing:
CBC
Hb
Ht
MCV
Platelet count
Leukocyte count
Segmented neutrophils
Bands
Eosinophils
Lymphocytes
Monocytes

13.8 g/dL
41%

91fl
320,000/cmm
6,000/cmm
70%
2%
2%
18%
8%

Serum chemistry
Serum Na
Serum K
Chloride
Bicarbonate
BUN
Serum creatinine
Calcium
Blood glucose

145 mEq/L
4.3 mEq/L
108 mEq/L
17 mEq/L
30 mg/dL
1.6 mg/dL
9.9 mg/dL
75 mg/dL

Total bilirubin
Direct bilirubin
Alkaline phosphatase
Aspartate aminotransferase
Alanine aminotransferase

1.3 mg/dL
0.8 mg/dL
200 U/L
150 U/L
11 0 U/L

LFT

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Total bilirubin
Direct bilirubin
Alkaline phosphatase
Aspartate aminotransferase
Alanine aminotransferase

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1.3 m g/dl
0.8 m g/dl
200 U/L
150 U/L
11 0 U/L

Gases, arterial blood


pH
pC02
p02

7.25
20 mm Hg
11 0 mm Hg

Item 2 of 2
W hich of the follow ing is the m ost appropriate next step in management?

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A. Intravenous antibiotics [1 %1
B. Oral lactulose and metronidazole [3%1
C. Intravenous furosemide [2%1
D. Non invasive mechanical ventilation [12%1

E. Alkaliniz ation of the urine [81%1

Explanation:

User ld:

The patient has m oderate metabolic acidosis, w ith a pH of 7.25, a bicarbonate level of 17 mEq/L and an anion
gap of 20 (obtained by subtracting the values of bicarbonate and chloride from the sodium). Her anion gap is
high (normal anion gap: 12, ranging from 8-16). Her slightly elevated BUN and creatinine levels indicate mild
renal failure, w hich can be due to dehydration or acute interstitial inflammation. Other abnormal findings are
the m oderately elevated aminotransferases, w hile the w hite blood cell count is normal. The clinical vignette is
consistent w ith aspirin overdose, w hich is associated w ith the development of acute renal failure and transient
hepatotoxicity, w hich can lead to coagulopathy, severe encephalopathy and non-cardiogenic pulmonary
edema . Therapy consists of gastric lavage, administration of activated charcoal, and alkalinization of the urine
to enhance secretion.

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r D. Non invasive mechanical ventilation [12%]


., r E. Alkaliniz ation of the urine [81%]
Explanation:

User ld:

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The patient has moderate metabolic acidosis, w ith a pH of 7.25, a bicarbonate level of 17 mEq/L and an anion
gap of 20 (obtained by subtracting the values of bicarbonate and chloride from the sodium). Her anion gap is
high (normal anion gap: 12, ranging from 8-16). Her slightly elevated BUN and creatinine levels indicate mild
renal failure, w hich can be due to dehydration or acute interstitial inflammation. Other abnormal findings are
the moderately elevated aminotransferases, w hile the w hite blood cell count is normal. The clinical vignette is
consistent w ith aspirin overdose, w hich is associated w ith the development of acute renal failure and transient
hepatotoxicity, w hich can lead to coagulopathy, severe encephalopathy and non-cardiogenic pulmonary
edema . Therapy consists of gastric lavage, administration of activated charcoal, and alkalinization of the urine
to enhance secretion.

(Choice C) The patient is dehydrated. Giving furosemide w ill aggravate her dehydrated status and renal
failure.
(Choice B) The encephalopathy in this case is due to intoxication and metabolic acidosis, not hepatic
disease. Lactulose and metronidazole w ill not be useful here.
(Choice D) Non-invasive mechanical ventilation is not needed as the patient does not have pC02 retention
and is not in ventilatory failure.
(Choice A) Even though the patient is febrile, antibiotics are not needed because the cause of her
hyperthermia is drug overdose, and there is no evidence of infection. Aspirin causes uncoupling of the
oxidative phosphorylation, resulting in hyperthermia .
Educational Objective:
Salicylate overdose presents w ith high anion gap metabolic acidosis, respiratory alkalosis, transient
hepatotoxicity, acute renal failure and depressed mental status. Therapy is aimed at eliminating the offending
agent through gastric lavage and administration of activated charcoal. It is important to determine salicylate
serum levels. Values greater than 35 mg/dl indicate significant acidosis, and alkalinization of the urine is
indicated to enhance aspirin excretion.
Time Spent: 6 seconds

Copyright USMLEW orld,LLC.

Last updated: [5/ 11/2014]

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A 32-year-old Caucasian female comes to the emergency department (ED) and complains of a generalized,
throbbing, headache that began during the night and got w orse in the morning. She has also brought in her
8-year-old son, w ho has a similar type of headache and nausea. She says that her husband w ent to w ork
today, although he w as not feeling w ell. She denies any previous illness, and has no idea w hat might have
brought these symptoms on. Her temperature is 36.7 C (98 F), blood pressure is 120/76 mm Hg, pulse is
90/min, and respirations are 16/min. No neck rigidity or meningeal signs are present on physical
examination. W hich of the follow ing tests can confirm the most probable diagnosis in this patient?

r A. Non-contrast CT scan of the head


r B. Lumbar puncture
r C. CBC w ith differential
r D. Carboxyhemoglobin level
r E. Serum acetaminophen level

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A 32-year-old Caucasian female comes to the emergency department (ED) and complains of a generalized,
throbbing, headache that began during the night and got w orse in the morning. She has also brought in her
8-year-old son, w ho has a similar type of headache and nausea. She says that her husband w ent to w ork
today, although he w as not feeling w ell. She denies any previous illness, and has no idea w hat might have
brought these symptoms on. Her temperature is 36.7 C (98 F), blood pressure is 120/76 mm Hg, pulse is
90/min, and respirations are 16/min. No neck rigidity or meningeal signs are present on physical
examination. W hich of the follow ing tests can confirm the most probable diagnosis in this patient?

r
r
r
., r
r

A. Non-contrast CT scan of the head [2%1


B. Lumbar puncture [4%1
C. CBC w ith differential [3%1
D. Carboxyhemoglobin level [90%1

E. Serum acetaminophen level [0%1

Explanation:

User ld:

The clinical scenario described is highly suggestive of carbon monoxide (CO) poisoning. The most important
feature that should be emphasized is the involvement of several people that have similar symptoms.
Interestingly, accidental CO poisoning has seasonal and regional variations, and are more common during
cold w inters in cold climates. The potential causes of the problem may be poorly functioning heating systems
or improperly vented fuel-burning devices (e.g., kerosene heater). Clinical symptoms of CO poisoning include
throbbing headaches, nausea, malaise and dizziness. Severe poisoning may result in seizures, syncope and
coma. Delayed neuropsychiatric syndrome develops in up to 40% of patients w ith significant CO poisoning.
The diagnosis is confirmed by carboxyhemoglobin level measurement.

(Choicees A and B) Other diagnoses such as subarachnoid hemorrhage and acute meningitis are unlikely in
this case.
(Choice C) CBC w ith differential w ould not assist in the differential diagnosis of this case.
(Choice E) Acetaminophen intoxication may initially manifest as nausea and vomiting, but eventually leads to
liver damage. The absence of acetaminophen intake in the history also makes the diagnosis unlikely.

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orougmmese symptoms on. Her temperature IS .jO. r t.- \~tl t-J, DIOOa pressure IS 1.::U/f o mm Hg, pUlse IS
90/min, and respirations are 16/min. No neck rigidity or meningeal signs are present on physical
examination. W hich of the follow ing tests can confirm the most probable diagnosis in this patient?

r
r
r
., r
r

A. Non-contrast CT scan of the head [2%1


B. Lumbar puncture [4%1
C. CBC w ith differential [3%1
D. Carboxyhemoglobin level [90%1

E. Serum acetaminophen level [0%1

Explanation:

User ld:

The clinical scenario described is highly suggestive of carbon monoxide (CO) poisoning. The most important
feature that should be emphasized is the involvement of several people that have similar symptoms.
Interestingly, accidental CO poisoning has seasonal and regional variations, and are more common during
cold w inters in cold climates. The potential causes of the problem may be poorly functioning heating systems
or improperly vented fuel-burning devices (e.g., kerosene heater). Clinical symptoms of CO poisoning include
throbbing headaches, nausea, malaise and dizziness. Severe poisoning may result in seizures, syncope and
coma. Delayed neuropsychiatric syndrome develops in up to 40% of patients w ith significant CO poisoning.
The diagnosis is confirmed by carboxyhemoglobin level measurement.

(Choicees A and B) Other diagnoses such as subarachnoid hemorrhage and acute meningitis are unlikely in
this case.
(Choice C) CBC w ith differential w ould not assist in the differential diagnosis of this case.
(Choice E) Acetaminophen intoxication may initially manifest as nausea and vomiting, but eventually leads to
liver damage. The absence of acetaminophen intake in the history also makes the diagnosis unlikely.
Educational Objective:
Clinical symptoms of CO poisoning include throbbing headache, nausea, malaise and dizziness. Several
people simultaneously presenting w ith a headache is an important clue. The diagnosis is confirmed by
carboxyhemoglobin level measurement.
Time Spent: 1 seconds

Copyright USMLEW orld,LLC.

Last updated: [9/22/20141

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A mother brings her 4-year-old son to the emergency department. She says, "He w as playing outside for
awhile, and w hen he came inside the house he suddenly seemed very sick ... he said his belly hurt, and his
muscles ached, and he w as sw eating and drooling and his eyes w ere w atering. He's acting really
confused. I've never seen him like this before." Immediately after arriving, the boy has an episode of severe
diarrhea. The child is sw eaty and very ill appearing. His pupils are constricted and he is heavily salivating. He
is w heezing and moderately tachypneic. Motor strength is reduced in all extremities, and there is evidence of
fasciculations. W hat should be administered to treat his symptoms?

r A. Pyridoxine
r B. N-acetylcysteine
r C. Naloxone
r D. Flumazenil
r E. Atropine and pralidoxime

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A mother brings her 4-year-old son to the emergency department. She says, "He w as playing outside for
awhile, and w hen he came inside the house he suddenly seemed very sick ... he said his belly hurt, and his
muscles ached, and he w as sw eating and drooling and his eyes w ere w atering. He's acting really
confused. I've never seen him like this before." Immediately after arriving, the boy has an episode of severe
diarrhea. The child is sw eaty and very ill appearing. His pupils are constricted and he is heavily salivating. He
is w heezing and moderately tachypneic. Motor strength is reduced in all extremities, and there is evidence of
fasciculations. W hat should be administered to treat his symptoms?

r
r
r
r
., r

A. Pyridoxine [4%1
B. N-acetylcysteine [2%1
C. Naloxone [2%1
D. Flumazenil [2%1

E. Atropine and pralidoxime [90%1

Explanation:

User ld:

Organophosphates are similar to nerve agents used in bio terrorism (e.g., sarin) and serve to inactivate
cholinesterases. This results in the excessive stimulation of cholinergic receptors (both muscarinic and
nicotinic) and in clinical manifestations of cholinergic toxicity. Serious organophosphate poisoning should be
treated w ith two medications: atropine, w hich reverses muscarinic receptor effects; and pralidoxime, w hich is
a cholinesterase activator (Choice E).
Pyridoxine (Choice A) is another term for Vitamin 86 and is used to treat isoniazid overdose. It is not useful in
treating organophosphate poisoning.
N-acetylcysteine (Choice B) is used to treat acetaminophen overdose. It is not useful in treating
organophosphate poisoning.
Naloxone (Choice C) reverses the effect of opioids. It is not useful in treating organophosphate poisoning.
Flumazenil (Choice D) is used to treat benzodiazepine overdose. It is not useful in treating organophosphate
poisoning.

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A. Pyridoxine [4%1
B. N-acetylcysteine [2%1
C. Naloxone [2%1
D. Flumazenil [2%1

E. Atropine and pralidoxime [90%1

Explanation:

User ld:

Organophosphates are similar to nerve agents used in bio terrorism (e.g., sarin) and serve to inactivate
cholinesterases. This results in the excessive stimulation of cholinergic receptors (both muscarinic and
nicotinic) and in clinical manifestations of cholinergic toxicity. Serious organophosphate poisoning should be
treated with two medications: atropine, which reverses muscarinic receptor effects; and pralidoxime, which is
a cholinesterase activator (Choice E).
Pyridoxine (Choice A) is another term for Vitamin 8 6 and is used to treat isoniazid overdose. It is not useful in
treating organophosphate poisoning.
N-acetylcysteine (Choice B ) is used to treat acetaminophen overdose. It is not useful in treating
organophosphate poisoning.
Naloxone (Choice C) reverses the effect of opioids. It is not useful in treating organophosphate poisoning.
Flumazenil (Choice D) is used to treat benzodiazepine overdose. It is not useful in treating organophosphate
poisoning.
Educational Objectiv e:
Serious organophosphate poisoning results in cholinergic toxicity and should be treated with two medications:
atropine, w hich reverses muscarinic receptor effects; and pralidoxime, which is a cholinesterase activator.
References:
1. The role of oximes in the management of organophosphorus pesticide poisoning.

Time Spent: 2 seconds

Copyright USMLEW orld,LLC.

Last updated: [7/ 1/20141

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A 24-year-old Caucasian male is brought to the emergency department by his girlfriend w ith lethargy and
shortness of breath . The girlfriend said that he felt okay two hours ago w hen she w as leaving for a w hile, 'just
a little bit exhausted' because they cleaned their house today. She found him confused and sleepy w hen she
returned home. His past medical history is insignificant. He does not smoke or consume alcohol and is not
know n to take recreational drugs. His blood pressure is 11 0/70 mmHg and heart rate is 50/min. A garlic-like
odor is present on his clothes. Physical examination reveals skin flushing and bilateral miosis. W heezing is
heard on lung auscultation. W hich of the follow ing is most likely to confirm the diagnosis in this patient?

r A. Urine toxicology
r B. RBC cholinesterase
r C. Chest x-ray
r D. Arterial blood gases
r E. Carboxyhemoglobin level

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A 24-year-old Caucasian male is brought to the emergency department by his girlfriend w ith lethargy and
shortness of breath . The girlfriend said that he felt okay two hours ago w hen she w as leaving for a w hile, 'just
a little bit exhausted' because they cleaned their house today. She found him confused and sleepy w hen she
returned home. His past medical history is insignificant. He does not smoke or consume alcohol and is not
know n to take recreational drugs. His blood pressure is 110/70 mmHg and heart rate is 50/min. A garlic-like
odor is present on his clothes. Physical examination reveals skin flushing and bilateral miosis. W heezing is
heard on lung auscultation . W hich of the follow ing is most likely to confirm the diagnosis in this patient?

r
., r
r
r
r

A. Urine toxicology [18%1


B. RBC cholinesterase [46%1
C. Chest x-ray [1 %1
D. Arterial blood gases [9%1

E. Carboxyhemoglobin level [25%1

Explanation:

User ld:

The symptoms and signs described are suggestive of organophosphate poisoning: confusion, lethargy,
bradycardia, skin flushing, miosis and w heezing are typical. Sudden onset of symptoms and garlic-like odor
from clothing are also characteristic. Direct measurement of RBC acetylcholinesterase activity provides a
measure of the degree of toxicity, but it is difficult to perform .

(Choice A) Urine toxicology is helpful in diagnosing intoxications w ith illicit drugs and some medications.
(Choice C) Certain radiopaque toxins may be visualized by plain film radiographs, e.g., chlorinated
hydrocarbons or iron tablets.
(Choice D) Arterial blood gases may help to diagnose salicylates, ethylene glycol, and methanol intoxications.
(Choice E) Carboxyhemoglobin level measurement may be done in patients w ith CO intoxication.
Educational Objective:
RBC cholinesterase activity test can be used to confirm the diagnosis of organophosphate poisoning and
assess the degree of severity.

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A 23-year-old Caucasian male presents to the emergency department w ith an acute onset of flushing, a
throbbing headache, palpitations and abdominal cramps. His symptoms began thirty minutes after eating fish
at a local restaurant. He says that his two friends w ho had the same dinner in the restaurant w ith him had
similar but milder symptoms. The particular fish that he ordered in the restaurant is his favorite, and he eats
this dish at least twice a month, but this time it tasted unusually spicy. His past medical history is
insignificant. W hich of the follow ing is the most likely cause of this patient's symptoms?

r A. Toxic shock
r B. Acute allergic reaction
r C. Carcinoid syndrome
r D. Scombroid poisoning
r E. Pufferfish poisoning

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A 23-year-old Caucasian male presents to the emergency department w ith an acute onset of flushing, a
throbbing headache, palpitations and abdominal cramps. His symptoms began thirty minutes after eating fish
at a local restaurant. He says that his two friends w ho had the same dinner in the restaurant w ith him had
similar but milder symptoms. The particular fish that he ordered in the restaurant is his favorite, and he eats
this dish at least twice a month, but this time it tasted unusually spicy. His past medical history is
insignificant. W hich of the follow ing is the most likely cause of this patient's symptoms?

r
r
r
., r
r

A. Toxic shock [4%]


B. Acute allergic reaction [8%]
C. Carcinoid syndrome [8%]
D. Scombroid poisoning [57%]

E. Pufferfish poisoning [24%]

Explanation:

User ld:

The clinical scenario described is consistent w ith scombroid poisoning, w hich is caused by the ingestion of
improperly stored seafood. If seafood is stored at temperatures exceeding 15C, histidine can undergo
decarboxylation and form histamine. Symptoms of scombroid poisoning include flushing, a throbbing
headache, palpitations, abdominal cramps, diarrhea, and oral burning. These typically begin 10-30 minutes
after ingesting the fish, and are self-limited. Patients sometimes describe a bitter taste, but this is not always
present. Physical findings may include skin erythema, w heezing, tachycardia and hypotension.

(Choice B) Scombroid poisoning is frequently misdiagnosed as an acute allergic reaction; how ever, the
development of similar symptoms in the patient's friends supports the former diagnosis.
(Choice E) Pufferfish poisoning is less common than scombroid poisoning, and is characterized by the
prominence of neurological symptoms (perioral tingling, incoordination, w eakness, etc).
(Choice A) Toxic shock is usually accompanied by high fever and hypotension.
(Choice C) Carcinoid syndrome is an unlikely diagnosis in this patient because his symptoms are clearly
associated w ith the fish ingestion.

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this dish at least twice a month, but this time it tasted unusually spicy. His past medical history is
insignificant. W hich of the follow ing is the most likely cause of this patient's symptoms?

r
r
r
., r
r

A. Toxic shock [4%]


B. Acute allergic reaction [8%]
C. Carcinoid syndrome [8%]
D. Scombroid poisoning [57%]

E. Pufferfish poisoning [24%]

Explanation:

User ld:

The clinical scenario described is consistent w ith scombroid poisoning, w hich is caused by the ingestion of
improperly stored seafood. If seafood is stored at temperatures exceeding 15C, histidine can undergo
decarboxylation and form histamine. Symptoms of scombroid poisoning include flushing, a throbbing
headache, palpitations, abdominal cramps, diarrhea, and oral burning. These typically begin 10-30 minutes
after ingesting the fish, and are self-limited. Patients sometimes describe a bitter taste, but this is not always
present. Physical findings may include skin erythema, w heezing, tachycardia and hypotension.

(Choice B) Scombroid poisoning is frequently misdiagnosed as an acute allergic reaction; how ever, the
development of similar symptoms in the patient's friends supports the former diagnosis.
(Choice E) Pufferfish poisoning is less common than scombroid poisoning, and is characterized by the
prominence of neurological symptoms (perioral tingling, incoordination, w eakness, etc).
(Choice A) Toxic shock is usually accompanied by high fever and hypotension.
(Choice C) Carcinoid syndrome is an unlikely diagnosis in this patient because his symptoms are clearly
associated w ith the fish ingestion.
Educational Objective:
The symptoms of scombroid poisoning include flushing, a throbbing headache, palpitations, abdominal
cramps, diarrhea, and oral burning. These typically begin 10-30 minutes after ingesting the fish, and are
self-limited.
Time Spent: 1 seconds

Copyright USMLEW orld,LLC.

l ast updated: [8/22/2014]

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The following vignette applies to the next 2 items


An older-appearing man of unknow n age is brought to the emergency department by paramedics on New
Year's Eve. They found him lying on the side of a street, minimally responsive. In the emergency department,
his core body temperature is 29 C (84.2 F), blood pressure is 70/30 mm Hg, heart rate is 40/min, and
respirations are 6/min and shallow . His oxygen saturation is 90% on 5 L of oxygen . On examination, the
patient remains unresponsive to verbal stimuli and his breath smells of alcohol. His pupils are normal and
symmetric but have a sluggish reaction to light. Lung examination show s crackles bilaterally. Cardiovascular
examination show s bradycardia w ith an irregular pulse. Neurologic examination is difficult to perform but
show s marked hyporeflexia throughout. An initial electrocardiogram show s sinus bradycardia w ith frequent
premature ventricular complexes. Capillary blood glucose is 315 mg/dl. Paramedics have started an
infusion of normal saline via 16-g peripheral access. The patient has also received one dose of intravenous
thiamine.

Item 1 of 2
W hich of the follow ing is the most appropriate next step in management of this patient?

r
r
r
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r

A. Atropine
B. Endotracheal intubation
C. Insertion of central line through subclavian vein
D. Insulin infusion

E. W arm intravenous fluids

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The following vignette applies to the next 2 items


An older-appearing man of unknow n age is brought to the emergency department by paramedics on New
Year's Eve. They found him lying on the side of a street, minimally responsive. In the emergency department,
his core body temperature is 29 C (84.2 F), blood pressure is 70/30 mm Hg, heart rate is 40/min, and
respirations are 6/min and shallow . His oxygen saturation is 90% on 5 l of oxygen . On examination, the
patient remains unresponsive to verbal stimuli and his breath smells of alcohol. His pupils are normal and
symmetric but have a sluggish reaction to light. l ung examination show s crackles bilaterally. Cardiovascular
examination show s bradycardia w ith an irregular pulse. Neurologic examination is difficult to perform but
show s marked hyporeflexia throughout. An initial electrocardiogram show s sinus bradycardia w ith frequent
premature ventricular complexes. Capillary blood glucose is 315 mg/dl. Paramedics have started an
infusion of normal saline via 16-g peripheral access. The patient has also received one dose of intravenous
thiamine.

Item 1 of 2
W hich of the follow ing is the most appropriate next step in management of this patient?

r
., r
r
r
r

A. Atropine [4%1
B. Endotracheal intubation [74%1
C. Insertion of central line through subclavian vein [2%1
D. Insulin infusion [1 %1

E. W arm intravenous fluids [20%1

Explanation:

User ld:

Clinical features of hypothermia


Mild

32-35 C (90-95 F)
Tachycardia, tachypnea & hyperventilation

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Clinical features of hypothermia

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Classi fication

& clini cal


presentation

32-35 C (9095 F)
Tachycardia, tachypnea & hyperventilation
Confusion, ataxia, dysarthria, increased shivering
Moderate
28-32 C (8290 F)
Bradycardia, lethargy, hypoventilation, decreased
shivering, loss of pupillary reflexes, atrial arrhythmias
Severe
< 28 C (82 F)
Coma, cardiovascular collapse, ventricular arrhythmias, pulmonary
edema
General
Possible endotracheal intubation in comatose patients
Warmed (42 C) crysta lloid for hypotension
Atrial arrhythmias usually resolve with hypothermia correction, but
ventricular arrhythmias treated according to ACLS protocol

Treatment

Rewarm ing t echniques*


Passive external warming (remove w et clothing, cover with blankets)
Active external warming (warm blankets, heating pads, warm baths)
Active internal rewarming (warmed IV fluids and humidified oxygen)
*Temperature may drop initially due to return of cold blood from the
extremities.

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This patient is suffering from m oderate hypothermia . Most patients w ith mild hypothermia (core body
temperature of 32-35 C [89.6-95 F]) present w ith confusion, ataxia, slurred speech, tachycardia, and
tachypnea . Patients w ith m oderate hypothermia (core temperature of 28-32 C [82.4-89.6 F]) may have
marked central nervous system depression along w ith hypoventilation, hypotension, bradycardia, hyporeflexia,
and cardiac conduction abnormalities. Severe hypothermia (core temperature <28 C [82.4 F]) can cause
marked hypotension, areflexia, coma, malignant ventricular arrhythmias (ventricular fibrillation), and asystole.
In light of this patient's hypoventilation, altered mental status, and hypoxemia, the next step in management is
endotracheal intubation to provide adequate ventilation and protect the airway. Bilateral crackles on
examination could be due to pulmonary edema, aspiration, or pneumonia. Endotracheal intubation should
protect against aspiration, help in oxygenation, and allow for suction of cold-induced bronchial secretions.

(Choice A) Bradycardia is a physiologic response to hypothermia and resolves w ith rew arming. Atropine or
cardiac pacing is not required unless the bradycardia persists after the temperature is corrected.
(Choice C) Central line placement to aid in fluid resuscitation w ould be appropriate. How ever, in
hypothermia, the heart is susceptible to cardiac arrhythmias w ith irritation, as could occur w ith jugular or
subclavian central lines. As a result, femoral lines are preferred. Patients w ith hypothermia should generally
be handled gently as rough handling can precipitate serious ventricular arrhythmias.
(Choice D) Many nondiabetic patients w ith m oderate-to-severe hypothermia are hyperglycemic as insulin
action stops at <30 C [86 F]. W arming these patients typically results in low ering of serum glucose.
(Choice E) This patient also needs rew arming, w hich should be started quickly after endotracheal
intubation. The interventions required for rew arming depend on the degree of hypothermia . For patients w ith
mild hypothermia, passive external w arming (removing w et clothes, increasing room temperature, and
covering w ith blankets) is generally adequate. For patients w ith m oderate hypothermia or mild hypothermia
not responding to passive rew arming, active external w arming (heated pads and blankets, forced hot air,
w arm baths) is required. Active core rew arming (w arm humidified oxygen, w arm intravenous fluids, w arm
peritoneal lavage) is reserved for patients w ith severe hypothermia (<28 C [82.4 F]) and those w ith m oderate
hypothermia not responding to external w arming. This patient needs room -temperature (not w arm)
intravenous fluids for resuscitation, w hich w ere started by paramedics, given his m oderate hypothermia and
hypotension,
Educational objective:
Endotracheal intubation is necessary in the unconscious hypothermic patient for adequate ventilation and
airway protection. Hypothermic patients should be handled gently to prevent cardiac arrhythmias. The
mP.thori of rP.w <'!rminn ciP.oP.nci!': on thP. ciP.nrP.P. of hvnothP.rmi<'!

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Item 2 of 2
Appropriate measures are initiated, and in an hour the patient's core temperature rises to 30 C (86 F). His
clinical status remains unchanged. Blood pressure is 82/42 mm Hg and heart rate is 42/min. His initial
laboratory results are as follow s:
Complete blood count
Hematocrit
Platelets
Leukocytes

56%
80,000/IJL
3,800/IJL

Serum chemistry
Sodium
Potassium
Chloride
Bicarbonate
Blood urea nitrogen
Creatinine
Calcium
Glucose

132 mEq/L
5.2 mEq/L
90 mEq/L
16 mEq/L
24 mgldl
1.4 mgldl
9.0 mgldl
290 mg/dl

Liver function studies


Albumin
Aspartate aminotransferase
Alanine aminotransferase
Lipase

4.3 g/dl
12 U/L
24 U/L
32 U/L

Coagulation studies
International Normalized Ratio
Activated partial thromboplastin time

2.0
48 sec

The cardiac monitor show s persistent sinus bradycardia w ith frequent premature ventricular contractions.
W hich of the follow ing is the most appropriate next step in management of this patient?

r A. Continuation of room-temperature intravenous fluids

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laboratory results are as follow s:

Complete blood count


Hematocrit
Platelets
Leukocytes

56%
80,000/IJL
3,800/IJL

Serum chemistry
Sodium
Potassium
Chloride
Bicarbonate
Blood urea nitrogen
Creatinine
Calcium
Glucose

132 mEq/L
5.2 mEq/L
90 mEq/L
16 mEq/L
24 mg/dl
1.4 mg/dl
9.0 mg/dl
290 mg/dl

Liver function studies


Albumin
Aspartate aminotransferase
Alanine aminotransferase
Lipase

4.3 g/dl
12 U/L
24 U/L
32 U/L

Coagulation studies
International Normalized Ratio
Activated partial thromboplastin time

2.0
48 sec

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The cardiac monitor show s persistent sinus bradycardia w ith frequent premature ventricular contractions.
W hich of the follow ing is the most appropriate next step in management of this patient?

r
r
r
r
r

A. Continuation of room-temperature intravenous fluids


B. Dopamine infusion
C. Fresh frozen plasma
D. Lidocaine infusion

E. W armed peritoneal lavage

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The cardiac monitor show s persistent sinus bradycardia with frequent premature ventricular contractions.
Which of the following is the most appropriate next step in management of this patient?

:I ~~ I
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., r
r
r
r
r

A. Continuation of room-temperature intravenous fluids [45%1


B. Dopamine infusion [24%1
C. Fresh frozen plasma [6%1
D. Lidocaine infusion [4%1
E. Warmed peritoneal lavage [22%1

Explanation:

User ld:

Laboratory abnormalities In hypothermi c patients


Abno rmality

M echani sm

Metabolic acidosis

Decreased tissue perfusion

Respiratory acidosis

Hypoventilation

Azotemia

Decreased renal perfusion

Hyperkalemia

Cellular lysis

Hyperglycemia*

Loss of insulin effect <30 C (86 F)

Elevated lipase

Cold-induced pancreatitis

Elevated hematocrit

Hemoconcentration

Coagulopathy

Impaired coagulation pathways

Leukopenia, thrombocytopenia

Splenic sequestration

* Hypoglycemia may be seen in a few patients for reasons that are unclear.
(c') I I ~M I I=Wnr&rl . l l C

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Coagulopathy

Impaired coagulation pathways

Leuko penia, thro mbocytopenia

Splenic sequestratio n

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* Hypoglycemia may be seen in a few patients for reasons that are unclear.
@USMLEWorld, U C

This patient has several biochemical abnormalities seen in hypothermia, including anion gap metabolic
acidosis, hyperglycemia, hyperkalemia, prolonged coagulation markers, high hematocrit, leukopenia, and
thrombocytopenia . Most of these laboratory abnormalities should normalize w ith improved tissue perfusion
and active external w arming. His core temperature has increased from 29 C (84.2 F) to 30 C (86 F) in 1
hour. The usual increase in core temperature w ith external w arming is around 1-2 C per hour, so this patient
is responding appropriately to interventions. The next step in management should be continuing to support
and improve his blood pressure and tissue perfusion w ith aggressive intravenous hydration .
(Choice B) Inotropic support w ith dopamine or dobutamine may be necessary if intravenous fluids and
w arming measures are ineffective in improving blood pressure. These agents have been show n to be safe in
hypothermic animal studies. How ever, trials in humans are limited, and fluid resuscitation is preferred.
(Choice C) This patient's coagulopathy is due to cold-induced inhibition of the clotting pathw ays and should
normalize as his core temperature improves. Treatment w ith fresh frozen plasma is not required at this time.
(Choice D) There is no evidence of malignant ventricular arrhythmia (eg, ventricular tachycardia) in this
patient. Antiarrhythmic drugs are not indicated for the treatment of frequent premature ventricular contractions.
(Choice E) Active external w arming is adequate for most patients w ith moderate hypothermia . Active core
rew arming may be required in some patients w ho do not respond to active external w arming and for those
w ith severe hypothermia (core temperature <28 C [82.4 F]).
Educational objective:
Hypothermia is associated w ith extensive biochemical abnormalities, such as metabolic and respiratory
acidosis, azotemia, hyperkalemia, hyperglycemia, hemoconcentration, and sequestration of w hite blood cells
and platelets. How ever, most of these abnormalities w ill resolve w ith appropriate w arming and hydration .
Aggressive intravenous hydration should be used to support low blood pressure in patients w ith hypothermia
and hypotension.

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A 77 -year-old Caucasian male is rescued from a house fire and is brought to the emergency department w ith
nausea, headache, and altered mental status. His past medical history is significant for hypertension,
hypercholesterolemia, and hypothyroidism. He is a non-smoker and non-alcoholic. His temperature is 36.7 C
(98 F), blood pressure is 11 0/70 mmHg, pulse is 80/min, and respirations are 16/min. W hich of the follow ing
is most helpful in diagnosing his underlying condition?

r A. Pulse oximetry
r B. Measurement of methemoglobin levels
r C. Measurement of arterial P02
r D. Measurement of venous P02
r E. CO-oximetry

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A 77 -year-old Caucasian male is rescued from a house fire and is brought to the emergency department w ith
nausea, headache, and altered mental status. His past medical history is significant for hypertension,
hypercholesterolemia, and hypothyroidism. He is a non-smoker and non-alcoholic. His temperature is 36.7 C
(98 F), blood pressure is 11 0/70 mmHg, pulse is 80/min, and respirations are 16/min. W hich of the follow ing
is most helpful in diagnosing his underlying condition?

r
r
r
r
., r

A. Pulse oximetry [7%1


B. Measurement of methemoglobin levels [42%1
C. Measurement of arterial P02 [1 5%1
D. Measurement of venous P0 2 [4%1

E. CO-oximetry [32%1

Explanation:

User ld:

The above patient is most likely suffering from carbon monoxide (CO) poisoning. The diagnosis is based on
the history and increased carboxyhemoglobin levels. Carboxyhemoglobin levels are measured by co-oximetry
of a blood gas sample. This spectrophotometric laboratory method can distinguish normal hemoglobin from
carboxyhemoglobin.

(Choice B) Carbon monoxide poisoning does not cause an increase in methemoglobin levels.
(Choices C and D) In carbon monoxide poisoning, there is no effect on the amount of oxygen dissolved in the
blood; therefore the P0 2 of arterial or venous blood is unaffected. Furthermore, an arterial blood gas is not
useful for diagnosing CO poisoning, except for identifying the metabolic acidosis from hypoxia.
(Choice A) Pulse oximetry reveals normal oxygen saturation levels in patients w ith carbon monoxide
poisoning, as it does not differentiate oxyhemoglobin from carboxyhemoglobin.
Educational objective:
CO-oximetry is used for the diagnosis of carbon monoxide poisoning.
Time Spent: 2 seconds

Copyright USMLEWorld,LLC.

Last updated: [4/23/20141

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An 8-year-old boy is brought to the emergency room by paramedics w ith a reported ingestion about four hours
ago. The patient had an accidental ingestion of "antifreeze" after mistaking it for a beverage in the garage.

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Item 1 of 2
W hich of the follow ing physical signs w ould be consistent w ith the history of "antifreeze" ingestion?

r A. Dry skin and mucosal surfaces


r B. Irregular heart rate
r C. Excessive salivation
r D. Pupillary dilation
r E. Rapid and deep breathing

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iThe following vignette a~~!!


lie
"Cs~
to~t~h!"e'-'n~eo;,x~t,_.2;_,i~
te
"'m
~
s------------------.....
An 8-year-old boy is brought to the emergency room by paramedics w ith a reported ingestion about four hours
ago. The patient had an accidental ingestion of "antifreeze" after mistaking it for a beverage in the garage.

Item 1 of 2
W hich of the follow ing physical signs w ould be consistent w ith the history of "antifreeze" ingestion?

r
r
r
r
., r

A. Dry skin and mucosal surfaces [8%1


B. Irregular heart rate [4%1
C. Excessive salivation [11 %1
D. Pupillary dilation [6%1

E. Rapid and deep breathing [71%1

Explanation:

User ld:

Ethylene glycol is one of the components of antifreeze and other solvents. It is one of the alcohols (along w ith
ethanol, methanol and isopropanol) w ith fatal intoxications. It is important to recognize its toxicity early for
instituting quick and definitive therapy.
Ethylene glycol gets metabolized in the body by an enzyme, alcohol dehydrogenase (ADH), into a variety of
toxic metabolites, including glycolic acid, glyoxylic acid, and oxalic acid. These toxic metabolites are
responsible for m ost of the clinical symptoms and organ damage seen w ith antifreeze ingestion .
Ethylene glycol ingestion leads to a severe anion gap metabolic acidosis. This causes a typical rapid and
deep breathing pattern know n as Kussmaul's respiration . Some of the other early signs include nausea,
vomiting, slurred speech, ataxia, nystagmus, and lethargy. Further toxicity may lead to tachypnea, agitation,
confusion, flank pain, renal failure, pulmonary edema, changes in mental status, and eventually, progression
to a coma.

(Choices A and D) Dry skin and mucosal surfaces, as w ell as dilated pupils, are seen in overdoses
of anticholinergic agents. The common agents implicated are tricyclic antidepressants, certain plants (Datura
s tramonium), and mushrooms.

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tyuc:u 11tc:u l 1c:nt: L<t 70 J

r C. Excessive salivation [11 %1


r D. Pupillary dilation [6%1
., r E. Rapid and deep breathing [71%1

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Explanation:

User ld:

Ethylene glycol is one of the components of antifreeze and other solvents. It is one of the alcohols (along w ith
ethanol, methanol and isopropanol) w ith fatal intoxications. It is important to recognize its toxicity early for
instituting quick and definitive therapy.
Ethylene glycol gets metabolized in the body by an enzyme, alcohol dehydrogenase (ADH), into a variety of
toxic metabolites, including glycolic acid, glyoxylic acid, and oxalic acid. These toxic metabolites are
responsible for most of the clinical symptoms and organ damage seen w ith antifreeze ingestion.
Ethylene glycol ingestion leads to a severe anion gap metabolic acidosis. This causes a typical rapid and
deep breathing pattern know n as Kussmaul's respiration. Some of the other early signs include nausea,
vomiting, slurred speech, ataxia, nystagmus, and lethargy. Further toxicity may lead to tachypnea, agitation,
confusion, flank pain, renal failure, pulmonary edema, changes in mental status, and eventually, progression
to a coma.

(Choices A and D) Dry skin and mucosal surfaces, as w ell as dilated pupils, are seen in overdoses
of anticholinergic agents. The common agents implicated are tricyclic antidepressants, certain plants (Datura
s tramonium), and mushrooms.
(Choice B) Ventricular tachyarrhythmias are seen w ith overdoses of tricyclic antidepressants and
second-generation antihistamines such as astemizole or terfenadine.
(Choice C) Excessive salivation is classically seen w ith organophosphate or carbamate poisoning. These are
commonly the agents used in pesticides and insecticides.
Educational Objective:
Ethylene glycol ingestion leads to a severe anion gap metabolic acidosis. This causes a typical rapid and
deep breathing pattern know n as Kussmaul's respiration.
Time Spent: 1 seconds

Copyright USMLEW orld,LLC.

l ast updated: [9/22/20141

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Item 2 of 2
W hich of the follow ing is the m ost appropriate treatment of early ethylene glycol ingestion?

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r A. Ethanol infusion
r B. Fomepizole infusion
r C. Ethanol and fomepizole infusions running together
r D. Ethanol infusion follow ed by fomepizole infusion
r E. Fomepizole infusion follow ed by ethanol infusion

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Item 2 of 2
W hich of the follow ing is the most appropriate treatment of early ethylene glycol ingestion?

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r
., r
r
r
r

A. Ethanol infusion [25%]


B. Fomepizole infusion [39%]
C. Ethanol and fomepizole infusions running together [9%]
D. Ethanol infusion follow ed by fomepizole infusion [19%]

E. Fomepizole infusion follow ed by ethanol infusion [8%]

Explanation:

User ld:

Early and prompt treatment of ethylene glycol ingestion is required to prevent permanent tissue damage and
death . Ethylene glycol gets metabolized in the body by an enzyme, alcohol dehydrogenase (ADH), into a
variety of toxic metabolites, including glycolic acid, glyoxylic acid, and oxalic acid. Fomepizole is a competitive
inhibitor of ADH, and is the antidote of choice in cases of ethylene glycol intoxication (and also methanol
intoxication). If used early, it prevents the formation of toxic metabolites, causes a dramatic improvement in
acidemia, and prevents renal failure. It also prolongs the half-life of ethanol; therefore, simultaneous use w ith
ethanol is not recommended (Choices C, 0, and E).

(Choice A) Ethanol can also be used for the treatment of patients w ith methanol or ethylene glycol
intoxication. Alcohol dehydrogenase actually has a greater affinity for ethanol than the other alcohols;
how ever, fomepizole inhibits ADH more potently than ethanol and is, therefore, the antidote of choice.

Educational Objective:
Fomepizole is the antidote of choice in cases of ethylene glycol and methanol intoxication. Simultaneous use
w ith ethanol is not recommended.
Time Spent: 2 seconds

Copyright USMLEW orld,LLC.

Last updated: [5/ 11/2014]

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A 24-year-old male is brought to the emergency department by his friend because of disorientation and
restlessness. This patient w as hospitalized one month ago for opioid overdose w ith subsequent aspiration
pneumonia. His blood pressure is 160/ 100 mmHg and heart rate is 120/min. He is not oriented in time and
space, but recalls his name and date of birth. Bilateral vertical nystagmus is present. W hich of the follow ing
is the best next step in the management of this patient?

r A. Diazepam
r B. Haloperidol
r C. Alkalization of urine
r D. Hemodialysis
r E. Low -stimulation environment

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A 24-year-old male is brought to the emergency department by his friend because of disorientation and
restlessness. This patient w as hospitalized one month ago for opioid overdose w ith subsequent aspiration
pneumonia. His blood pressure is 160/ 100 mmHg and heart rate is 120/min. He is not oriented in time and
space, but recalls his name and date of birth. Bilateral vertical nystagmus is present. W hich of the follow ing
is the best next step in the management of this patient?

r
r
r
r
., r

A. Diazepam [29%1
B. Haloperidol [8%1
C. Alkalization of urine [1 7%1
D. Hemodialysis [5%1

E. Low -stimulation environment [40%1

Explanation:

User ld:

This patient presents w ith symptoms and signs suggestive of phencyclidine (PCP) intoxication. Although high
doses of many CNS depressants may also produce nystagmus, the scenario is typically associated w ith
prominent sedation; nystagmus in awake or agitated patients is characteristic for PCP intoxication.
This patient is disoriented and restless, but is not agitated or show s aggressive behavior. Placement in
a quiet environment, along w ith metabolic and hemodynamic control, is the most reasonable approach.

(Choice A) Benzodiazepines are used to treat agitation and seizures in these patients.
(Choice B) Haloperidol is typically required in patients w ho demonstrate aggressive behavior.
(Choice C) PCP is a w eak base. Alkalization of the urine is not helpful for its removal.
(Choice D) PCP has a large volume of distribution (good tissue penetration). Hemodialysis cannot effectively
remove the drug from the body.
Educational Objective:
A low -stimulation environment is ideal for patients w ith PCP intoxication.

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A 38-year-old African American man comes to the emergency department after experiencing severe back
pain for the past 2 days. He has a history of hypertension for the last 5 years. His current medications
include hydrochlorothiazide, amlodipine, and valsartan . The patient has a 15-pack-year history and drinks 4-5
bottles of beer daily. His temperature is 36.7 C (98 F), blood pressure is 230/ 112 mm Hg, and pulse is
84/min. Funduscopic examination show s arteriolar w all thickening and occasional cotton-w ool spots. The
rest of the examination is w ithin normal limits. Initial laboratory studies show serum blood urea nitrogen of 28
mg/dl , potassium of 5.1 mEq/L, and serum creatinine of 2.3 mg/dl. Transesophageal echocardiogram is
consistent w ith dissection in the descending aorta . The patient is admitted to the coronary care unit and
started on intravenous labetalol and nitroprusside infusion. The next morning, the nurse finds him confused
and agitated. He then has a generalized tonic-clonic seizure. His temperature is 36.7 C (98 F), blood
pressure is 176/99 mm Hg, and pulse is 102/min. Physical examination remains otherwise unchanged.
W hich of the follow ing is the most likely diagnosis?

r A. Cyanide toxicity
r B. Excessive hypotensive response
r C. Extension of the dissection to the aortic arch
r D. Hypertensive encephalopathy
r E. Intracranial hemorrhage

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A 38-year-old African American man comes to the emergency department after experiencing severe back
pain for the past 2 days. He has a history of hypertension for the last 5 years. His current medications
include hydrochlorothiazide, amlodipine, and valsartan . The patient has a 15-pack-year history and drinks 4-5
bottles of beer daily. His temperature is 36.7 C (98 F), blood pressure is 230/ 11 2 mm Hg, and pulse is
84/min. Funduscopic examination show s arteriolar w all thickening and occasional cotton-w ool spots. The
rest of the examination is w ithin normal limits. Initial laboratory studies show serum blood urea nitrogen of 28
mg/dl , potassium of 5.1 mEq/L, and serum creatinine of 2.3 mg/dl. Transesophageal echocardiogram is
consistent w ith dissection in the descending aorta. The patient is admitted to the coronary care unit and
started on intravenous labetalol and nitroprusside infusion. The next morning, the nurse finds him confused
and agitated. He then has a generalized tonic-clonic seizure. His temperature is 36.7 C (98 F), blood
pressure is 176/99 mm Hg, and pulse is 102/min. Physical examination remains otherwise unchanged.
W hich of the follow ing is the most likely diagnosis?

.., r
r
r
r
r

A. Cyanide toxicity [50%]


B. Excessive hypotensive response [1 2%]
C. Extension of the dissection to the aortic arch [9%]

D. Hypertensive encephalopathy [1 9%]


E. Intracranial hemorrhage [1 0%]

User ld:

Explanation:

Manifestations of cyanide accumulation and toxicity

Skin: Flushing (cherry-red color), cyanosis (occurs later)


Central nervous system: Headache, altered mental status, seizures, coma
Cardiovascular: Arrhythmias
Respiratory: Tachypnea followed by respiratory depression, pulmonary edema
Gastrointestinal: Abdominal pain, nausea, vomiting
Renal: Metabolic acidosis (from lactic acidosis), renal failure

@ USMLEWorld.llC

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This patient's symptoms suggest acute cyanide toxicity in the setting of renal failure and nitroprusside use.
Nitroprusside is a potent vasodilator that w orks on both arterial and venous circulation and is used for
hypertensive emergency management. It has rapid onset and offset of action. The most important side effect
is cyanide accumulation and toxicity.
Patients w ith chronic renal failure or those receiving a high-dose or prolonged infusion of sodium nitroprusside
are at increased risk for cyanide toxicity. As a result, low infusion rates (<2 ~/kg/min), short-term usage, and
close monitoring are recommended. Treatment involves cessation of nitroprusside and administration of
sodium thiosulfate.

(Choice B) The initial goal in hypertensive emergencies is to rapidly low er diastolic pressure to 100-105 mm
Hg over 2-6 hours, w ith the total drop in blood pressure being no more than 25% of the initial value. Excessive
hypotensive therapy w ith sudden drop in blood pressure can lead to ischemic events (eg, cerebral ischemia,
m yocardial infarction), altered mental status, or generalized seizures. How ever, this patient's blood pressure
drop is not excessive enough to cause cerebral ischemia.
(Choice C) Extension of dissection to the aortic arch and/or carotid arteries can cause symptoms and signs
suggestive of a stroke (aphasia w ith associated motor or sensory abnormalities). It w ould not be expected to
cause altered mental status or seizures.
(Choice D) Rapid and severe rise in blood pressure causes increased cerebral perfusion pressure, w hich
results in cerebral edema and hypertensive encephalopathy. Patients typically complain of insidious onset of
headaches, nausea, and vomiting; this can progress to restlessness, confusion, agitation, seizures, and
coma. This patient's blood pressure has actually improved w ith treatment, w hich is not suggestive of
hypertensive encephalopathy.
(Choice E) Patients w ith intracerebral hemorrhage typically develop headache and/or vomiting. Seizures
may occur and are more common in lobar hemorrhages than other types of intracerebral hemorrhage.
Patients typically have focal neurologic deficits such as hemiplegia or paresis and hemianopsia .
Educational objective:
Nitroprusside is frequently used in the management of acute hypertensive emergency. It is metabolized to
cyanide, w hich may accumulate and can be toxic in patients w ith chronic renal failure or those receiving a
high-dose or prolonged infusion. Toxicity should be suspected in all patients on nitroprusside infusion w ho
have unexplained metabolic acidosis and altered mental status.
Time Spent: 1 seconds

Copyright USMLEW orld,LLC.

Last updated: [61912014]

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A 41 -year-old man comes to the emergency department after being stung by a w asp on his right arm 2 hours
ago. He complains of generalized itching and mild local pain . He has no other medical problems. His
temperature is 36.7 C (98 F), blood pressure is 122181 mm Hg, pulse is 96/min, and respirations are 14/min.
Pulse oximetry is 96% on room air. Examination show s a 2x2-cm, erythematous, elevated, w arm, and mildly
tender area on the right arm . Multiple w heals are visible on his trunk and extremities. There is no tongue
sw elling or stridor. Bilateral w heezes are present on lung auscultation. His heart sounds and the remainder
of his examination are normal. W hich of the follow ing is the most appropriate next step in management of this
patient?

r A. Inhaled albuterol
r B. Intramuscular epinephrine
r C. Intravenous diphenhydramine
r D. Intravenous methylprednisolone
r E. Oral hydroxyzine

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A 41 -year-old man comes to the emergency department after being stung by a w asp on his right arm 2 hours
ago. He complains of generalized itching and mild local pain . He has no other medical problems. His
temperature is 36.7 C (98 F), blood pressure is 122/81 mm Hg, pulse is 96/min, and respirations are 14/min.
Pulse oximetry is 96% on room air. Examination show s a 2x2-cm, erythematous, elevated, w arm, and mildly
tender area on the right arm . Multiple w heals are visible on his trunk and extremities. There is no tongue
sw elling or stridor. Bilateral w heezes are present on lung auscultation. His heart sounds and the remainder
of his examination are normal. W hich of the follow ing is the most appropriate next step in management of this
patient?

r
., r
r
r
r

A. Inhaled albuterol [5%]


B. Intramuscular epinephrine [56%]
C. Intravenous diphenhydramine [26%]
D. Intravenous methylprednisolone [6%]

E. Oral hydroxyzine [6%]

Explanation:

User ld:

Anaphylaxis is a systemic allergic response that occurs acutely follow ing exposure to a know n or potential
allergen . If this patient's allergic response consisted of hives and itching localized to the site of the w asp sting
alone, treatment w ith an antihistamine such as diphenhydramine w ould likely have sufficed. How ever, given
that the skin findings are generalized and accompanied by w heezing on auscultation, this patient is
experiencing anaphylaxis and more aggressive treatment is w arranted.
Hypotension is frequently seen in patients w ith anaphylaxis but may be delayed or absent. Therefore, the lack
of hypotension does not exclude the diagnosis. Gastrointestinal symptoms such as nausea, vomiting,
diarrhea, and crampy abdominal pain may also occur. The presentation of anaphylaxis is variable, and the
absence of certain findings does not exclude the diagnosis in the appropriate clinical context.
The best next step in this patient w ould be administration of intramuscular epinephrine. Intramuscular
injection results in a far more rapid rise in blood levels compared to subcutaneous injection. Intravenous
epinephrine is associated w ith increased risk of dosing errors and adverse side effects (eg, arrhythmias); it is
reserved for refractory hypotension or bronchospasm .
Patients should be educated about proper use of self-injectable epinephrine and the importance of carrying

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"-"-VIIItJOIIICU u y ~V IICC"-III Y V II OU~ "- UilOU V II )

Ull~ IJOUCIIll~

experiencing anaphylaxis and more aggressive treatment is warranted.


Hypotension is frequently seen in patients with anaphylaxis but may be delayed or absent. Therefore, the lack
of hypotension does not exclude the diagnosis. Gastrointestinal symptoms such as nausea, vomiting,
diarrhea, and crampy abdominal pain may also occur. The presentation of anaphylaxis is variable, and the
absence of certain findings does not exclude the diagnosis in the appropriate clinical context.
The best next step in this patient would be administration of intramuscular epinephrine. Intramuscular
injection results in a far more rapid rise in blood levels compared to subcutaneous injection. Intravenous
epinephrine is associated with increased risk of dosing errors and adverse side effects (eg, arrhythmias); it is
reserved for refractory hypotension or bronchospasm.
Patients should be educated about proper use of self-injectable epinephrine and the importance of carrying
this potentially life-saving medication at all times. In addition, they should be referred to an allergist for venom
immunotherapy, which can reduce repeat bee sting anaphylaxis risk from 60% to < 5%.
Bronchodilators (Choice A) and antihistamines (Choices C and E) are helpful supplemental therapies for
anaphylaxis. Intravenous methylprednisolone (Choice D) is helpful in preventing a relapsing or prolonged
anaphylactic reaction. However, inappropriate prioritization of these adjunctive therapies with anaphylaxis can
result in delay in epinephrine administration and cardiopulmonary decompensation.
Educational objective:

Anaphylaxis should be suspected in patients with cutaneous, respiratory, gastrointestinal, and cardiovascular
symptoms after exposure to a known or potential allergen. Its presentation is variable, and it is not necessary
to have every sign and symptom for diagnosis. Epinephrine should be given intramuscularly if there is
concern for anaphylaxis.
References:

1. 2012 update: World Allergy Organization Guidelines for the assessment and management
of anaphylaxis.

2. Epinephrine absorption in adults: intramuscular versus subcutaneous injection.


3. Venom immunotherapy for preventing allergic reactions to insect stings.

Time Spent: 2 seconds

Copyright USMLEWorld,LLC.

Last updated: [4/8/2014]

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A 56-year-old w oman in the emergency department w aiting room complains of shortness of breath and
generalized itching. She w as eating a cookie w hile w aiting for her husband w hen her symptoms started. The
patient is allergic to peanuts and believes the cookie contained them . She has a history of emphysema and a
20-pack-year smoking history. Her temperature is 36.7 C (98 F), blood pressure is 88/60 mm Hg, pulse is
124/min, and respirations are 26/min. Pulse oximetry is 92% on room air. She is using the accessory
muscles of her neck and shoulder girdle and is exhaling through pursed lips. There is no tongue sw elling or
stridor. Bilateral w heezes are present on lung auscultation. Skin examination is show n in the photograph
below .

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Which of the following is the most appropriate next step in management of this patient?

r A. Intramuscular epinephrine
r B. Intravenous methylprednisolone
r C. Intravenous normal saline
r D. Inhaled albuterol
r E. Subcutaneous epinephrine

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A 56-year-old w oman in the emergency department w aiting room complains of shortness of breath and
generalized itching. She w as eating a cookie w hile w aiting for her husband w hen her symptoms started. The
patient is allergic to peanuts and believes the cookie contained them . She has a history of emphysema and a
20-pack-year smoking history. Her temperature is 36.7 C (98 F), blood pressure is 88/60 mm Hg, pulse is
124/min, and respirations are 26/min. Pulse oximetry is 92% on room air. She is using the accessory
muscles of her neck and shoulder girdle and is exhaling through pursed lips. There is no tongue sw elling or
stridor. Bilateral w heezes are present on lung auscultation. Skin examination is show n in the photograph
below .

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W hich of the follow ing is the most appropriate next step in management of this patient?

., r
r
r
r
r

A. Intramuscular epinephrine [84%]


B. Intravenous methylprednisolone [2%]
C. Intravenous normal saline [1 %]
D. Inhaled albuterol [1 %]

E. Subcutaneous epinephrine [1 3%]

Explanation:

User ld:

This patient is experiencing anaphylaxis, a life-threatening, systemic allergic reaction that occurs acutely after
exposure to a know n or potential allergen . Skin and mucous membrane symptoms are common and include
itching, hives, and sw elling of the lips and/or tongue. How ever, 10%-20% of patients w ith anaphylaxis have no
skin findings, so their absence does not exclude the diagnosis. Respiratory distress is also common and can
be particularly severe in the setting of underlying pulmonary problems such as emphysema . Gastrointestinal
symptoms such as nausea, vomiting, diarrhea, and crampy abdominal pain may also occur. In many cases,
hypotension may be the only manifestation of anaphylaxis. The presentation of anaphylaxis is variable, and
the absence of certain findings does not exclude the diagnosis in the appropriate clinical context.
This patient's circulation, airway, and breathing should be assessed rapidly, and intramuscular epinephrine
should be administered immediately into the thigh. The intramuscular route is preferred over subcutaneous
injection (Choice E) due to its faster effect. The patient should be placed in a supine position (or semirecumbent if dyspneic or vomiting) w ith elevation of the low er extremities. Any patient w hose hypotension
does not respond promptly and completely should receive large-volume fluid resuscitation w ith a crystalloid
such as normal saline (Choice C). Intravenous epinephrine may be necessary if the patient's blood pressure
w orsens despite intramuscular epinephrine and fluid resuscitation.

(Choice B) Glucocorticoids such as methylprednisolone can be helpful in preventing prolonged or biphasic


reactions. How ever, glucocorticoids need several hours to take effect and do not provide the immediate
action required in this emergency situation.
(Choice D) The J32 agonist effect from albuterol can help relieve low er-airway obstruction (eg,
w heezing). How ever, albuterol does not relieve other dangerous symptoms of anaphylaxis such as upperairway edema (eg, stridor) or hypotension.

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Ill. I lillY , III V C~ , CU IU ::.VVCIIIIIY U l liiC lltJ~ CU IUfUI l U IIY UC.

n U W C V tl ,

I V 7 0 - L V 7 0 U l tJCIUCIIl::. W illi CU ICitJII Y ICIAI~ IICIV C IIU

skin findings, so their absence does not exclude the diagnosis. Respiratory distress is also common and can
be particularly severe in the setting of underlying pulmonary problems such as emphysema . Gastrointestinal
symptoms such as nausea, vomiting, diarrhea, and crampy abdominal pain may also occur. In many cases,
hypotension may be the only manifestation of anaphylaxis. The presentation of anaphylaxis is variable, and
the absence of certain findings does not exclude the diagnosis in the appropriate clinical context.
This patient's circulation, airway, and breathing should be assessed rapidly, and intramuscular epinephrine
should be administered immediately into the thigh. The intramuscular route is preferred over subcutaneous
injection (Choice E) due to its faster effect. The patient should be placed in a supine position (or semirecumbent if dyspneic or vomiting) w ith elevation of the low er extremities. Any patient w hose hypotension
does not respond promptly and completely should receive large-volume fluid resuscitation w ith a crystalloid
such as normal saline (Choice C). Intravenous epinephrine may be necessary if the patient's blood pressure
w orsens despite intramuscular epinephrine and fluid resuscitation.

(Choice B) Glucocorticoids such as methylprednisolone can be helpful in preventing prolonged or biphasic


reactions. How ever, glucocorticoids need several hours to take effect and do not provide the immediate
action required in this emergency situation.
(Choice D) The 132 agonist effect from albuterol can help relieve low er-airway obstruction (eg,
w heezing). How ever, albuterol does not relieve other dangerous symptoms of anaphylaxis such as upperairway edema (eg, stridor) or hypotension.
Educational objective:
Anaphylaxis presents w ith hives, w heezing, gastrointestinal symptoms, and/or hypotension follow ing exposure
to a know n or potential allergen . The first-line treatment is rapid administration of intramuscular epinephrine
w ith the patient in a supine or semi-recumbent position. Fluid resuscitation, bronchodilators, antihistamines,
and glucocorticoids may also be required.
References:
1. Epinephrine (adrenaline) in anaphylaxis.

2. 2012 update: World Allergy Organization guidelines for the assessment and management
of anaphylaxis.

Time Spent: 4 seconds

Copyright USMLEW orld,LLC.

Last updated: [41812014]

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A 55-year-old Caucasian male is brought to the emergency department by an ambulance after collapsing at a
local golf course on a hot summer day. The man had been golfing w ith friends for several hours, w hen he
reported feeling dizzy and seemed confused. His temperature is 41 .2C (106.2F), blood pressure is 110/68
mm Hg, pulse is 104/min, and respirations are 25/min. The man is now unconscious. His skin is hot, dry,
and flushed. W hich of the follow ing should be undertaken first in managing this condition?

r A. Give an alcohol sponge bath


r B. Augment evaporative cooling
r C. Perform ice w ater gastric and rectal lavage
r D. Administer acetaminophen
r E. Administer phenylephrine

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A 55-year-old Caucasian male is brought to the emergency department by an ambulance after collapsing at a
local golf course on a hot summer day. The man had been golfing w ith friends for several hours, w hen he
reported feeling dizzy and seemed confused. His temperature is 41 .2C (106.2F), blood pressure is 11 0/68
mm Hg, pulse is 104/min, and respirations are 25/min. The man is now unconscious. His skin is hot, dry,
and flushed. W hich of the follow ing should be undertaken first in managing this condition?

A. Give an alcohol sponge bath [4%1

r
B. Augment evaporative cooling [71%1

17

C. Perform ice w ater gastric and rectal lavage [1 8%1

r
D. Administer acetaminophen [5%1

r
E. Administer phenylephrine [2%1

Explanation:

User ld:

Heat stroke is a life-threatening emergency that occurs w hen an individual is exposed to the sun for an
extended period, but does not sw eat enough to low er the body temperature. Infants, the elderly, and people
w ho w ork outdoors are especially prone to developing heat stroke. The most common symptoms of heat
stroke include hyperthermia, tachycardia, loss of consciousness, seizure, fatigue, headache, dizziness,
agitation or confusion, and hot dry skin that is flushed but not sw eaty. Once the heat stroke is recognized, the

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Explanation:

User ld:

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17

Heat stroke is a life-threatening emergency that occurs w hen an individual is exposed to the sun for an
extended period, but does not sw eat enough to low er the body temperature. Infants, the elderly, and people
w ho w ork outdoors are especially prone to developing heat stroke. The most common symptoms of heat
stroke include hyperthermia, tachycardia, loss of consciousness, seizure, fatigue, headache, dizziness,
agitation or confusion, and hot dry skin that is flushed but not sw eaty. Once the heat stroke is recognized, the
patient should be immediately removed from the hot environment, and his airway, breathing, and circulation
(ABC's) should be stabilized. The initiation of rapid cooling is crucial, and the naked patient should be sprayed
w ith a tepid w ater mist or covered w ith a w et sheet w hile large fans circulate air to maximize evaporative heat
loss. Ideally, the patient's core temperature should be dropped by 0.2C/min.

(Choice A) An alcohol sponge bath is contraindicated in heat stroke because a significant proportion of the
toxin can be absorbed through the dilated cutaneous vessels.
(Choice C) Ice w ater gastric and rectal lavage may be helpful in speeding the cooling of the patient, but are
used solely as adjuncts to evaporative cooling. They should not be the first step taken in managing any heat
stroke patient.
(Choice D) Antipyretics such as acetaminophen are not indicated because the cause of the increased body
temperature is not an increased hypothalamic set point. Hepatic damage can also be w orsened by large
doses of acetaminophen.
(Choice E) Phenylephrine is an alpha-adrenergic agonist indicated in shock and severe hypotension . It is
contraindicated in heat stroke because it causes vasoconstriction and slow s cooling.
Educational Objective:
Heat stroke should be treated w ith augmentation of evaporative cooling, and the naked patient should be
sprayed w ith a tepid w ater mist or covered w ith a w et sheet w hile large fans circulate air to maximize
evaporative heat loss. Other cooling methods such as ice packs, ice w ater lavage, or cold intravenous fluids
are helpful adjuncts, but not first-line treatments.
Time Spent: 2 seconds

Copyright USMLEW orld,LLC.

l ast updated: [8/22/2014]

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A 25-year-old male machinery operator is brought to the emergency department by an ambulance


immediately after sustaining chemical burns to his hands and arms. He w as w orking in a nearby industrial
w arehouse, w hen a carton containing an unknow n chemical pow der w as knocked over onto him. Much of the
pow der remains on his hands and arms. He is in great pain, and is unable to answ er any further questions.
W hat is the appropriate initial intervention?

r A. Rinse the pow der off immediately w ith copious cold w ater
r B. Rinse the pow der off immediately w ith sterile saline
r C. Rinse the pow der off immediately w ith sterile Ringer's lactate
r D. Rinse the pow der off immediately w ith neutralizing solution
E. Brush the pow der off immediately

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A 25-year-old male machinery operator is brought to the emergency department by an ambulance


immediately after sustaining chemical burns to his hands and arms. He w as w orking in a nearby industrial
w arehouse, w hen a carton containing an unknow n chemical pow der w as knocked over onto him. Much of the
pow der remains on his hands and arms. He is in great pain, and is unable to answ er any further questions.
W hat is the appropriate initial intervention?

r
r
r
r

., r

A. Rinse the pow der off immediately w ith copious cold w ater [36%]
B. Rinse the pow der off immediately w ith sterile saline [1 5%]

C. Rinse the pow der off immediately w ith sterile Ringer's lactate [2%]

D. Rinse the pow der off immediately w ith neutralizing solution [12%]

E. Brush the pow der off immediately [35%]

Explanation:

User ld:

W hen an incident involving exposure to hazardous materials occurs, it is important for emergency personnel
to accomplish two goals: the treatment of exposed individuals, and the containment of any remaining
hazardous materials. Unknow n dry chemicals should always be brushed off first.

(Choice A) Only after the remaining visible pow der is removed should the area be irrigated w ith copious
amounts of low -pressure w ater for 15-30 minutes. Unknow n liquid chemicals, in contrast, are simply
immediately w ashed off w ith w ater. The victim's clothing should be promptly removed and stored in a plastic
bag, although irrigation should begin before the victim is undressed.
(Choices 8 and C) Rinsing the pow der off w ith sterile saline or sterile Ringer's lactate is not recommended.
Cold w ater is the agent of choice once the pow der has been brushed away from the skin .

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r 1::!. K 1nse the pow der ott1mmed1ately With stenle saline [1 b% J

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r
r

., r

C. Rinse the pow der off immediately w ith sterile Ringer's lactate [2%]
D. Rinse the pow der off immediately w ith neutralizing solution [12%]

E. Brush the pow der off immediately [35%]

Explanation:

User ld:

W hen an incident involving exposure to hazardous materials occurs, it is important for emergency personnel
to accomplish two goals: the treatment of exposed individuals, and the containment of any remaining
hazardous materials. Unknow n dry chemicals should always be brushed off first.

(Choice A) Only after the remaining visible pow der is removed should the area be irrigated w ith copious
amounts of low -pressure w ater for 15-30 minutes. Unknow n liquid chemicals, in contrast, are simply
immediately w ashed off w ith w ater. The victim's clothing should be promptly removed and stored in a plastic
bag, although irrigation should begin before the victim is undressed.
(Choices B and C) Rinsing the pow der off w ith sterile saline or sterile Ringer's lactate is not recommended.
Cold w ater is the agent of choice once the pow der has been brushed away from the skin .
(Choice D) Rinsing the pow der off w ith a neutralizing solution is inadvisable, even if the pow der is know n to
be an acid or alkali . Animal studies have demonstrated that animals w ith acid or alkali burns that w ere
w ashed w ith w ater survived longer than those w ashed w ith neutralizing solution. It has been postulated that
the additional damage caused by the heat of the exothermic neutralization reaction is responsible for this
increased mortality.
Educational Objective:
Dry unknow n chemicals should always be brushed off of the skin first. Once the remaining visible pow der is
removed, then the area should be irrigated w ith copious amounts of low -pressure w ater.
Time Spent: 5 seconds

Copyright USMLEW orld,LLC.

l ast updated: [5/11 /2014]