Which of the following is not a surgically correctable cause of hypertension?
Correct Answer D: Coarctation of the aorta is localized narrowing of the aortic lumen that results in upper-extremity hypertension. Treatment is balloon angioplasty with stent placement, or surgical correction.
Renal artery occlusion is acute or chronic interruption of blood flow through one or both of the main renal arteries or its branches, usually due to thromboemboli, atherosclerosis, or fibromuscular dysplasia. Chronic, progressive occlusion causes refractory hypertension and may lead to chronic renal failure. Treatment of chronic, progressive occlusion includes angioplasty with stenting, surgical bypass, and removal of an infarcted kidney.
A pheochromocytoma is a catecholamine-secreting tumor of chromaffin cells typically located in the adrenals. It causes persistent or paroxysmal hypertension. Treatment involves surgical removal of the tumor when possible.
Essential hypertension, which comprises 90-95% of all cases of hypertension occurs through no secondary cause. It is treated with lifestyle modifications, diet, exercise and medications.
Which of the following is true regarding mandibular fractures?
Correct Answer D: Fractures of the lower jaw (mandible) are suspected in patients with post-traumatic malocclusion or focal swelling and tenderness over a segment of the mandible. Other clues include defects of the dental occlusal surface, alveolar ridge disruptions, and anesthesia in the distribution of the inferior alveolar or mental nerve.
A 40-year-old woman presents to the ED with fever, no nausea or vomiting, and left flank pain radiating to the groin. Body CT reveals 8 mm stone in the left proximal ureter.
You should:
Correct Answer D: As stones increase in size beyond 4 mm, the need for urologic intervention increases exponentially. Referral to a urologist is indicated for patients with a stone greater than 5 mm in size for possible surgical intervention (stent placement). Referral is also indicated for patients with a ureteral stone that has not passed after two to four weeks of observation. The complication rate for ureteral calculi has been reported to almost triple (to 20 percent) when symptomatic stones are left untreated beyond four weeks.
A 24-year-old woman arrives at the Emergency Department unconscious. Her BP is 90/60 mmHg, her heart rate is 60 bpm, she is breathing at 8 breaths per minute and her O2 sat is 86%. Her eyes remain closed even after pain stimulation and the only sounds she makes are incomprehensible. Her arms or legs flexed briskly in response to pain.
This patient’s Glasgow coma score (GCS) score is:
Correct Answer D: Glasgow Coma Scale (GCS) is designed for use on trauma patients with decreased LOC (level of consciousness). It is a good indicator of severity of injury and is often used for metabolic causes as well. It is most useful if repeated; changes in GCS with time are more relevant than the absolute number. The patient with deteriorating GCS needs immediate attention.
The GCS is best reported as a 3 part score: Eyes + Verbal + Motor = Total.
Eyes:
Verbal:
Motor:
GCS provides an indication of the degree of injury:
This patient has scores of 1, 2 and 3 to the three questions respectively, making his GCS score 6.
Which physical exam finding below is usually not associated with increasing intracranial pressure?
Correct Answer B: In general, symptoms and signs that suggest a rise in ICP including headache, nausea, vomiting, ocular palsies, altered level of consciousness, and papilledema. If papilledema is protracted, it may lead to visual disturbances, optic atrophy, and eventually blindness.
In addition to the above, if mass effect is present with resulting displacement of brain tissue, additional signs may include pupillary dilatation, abducens (Cranial nerve VI) palsies, and the Cushing's triad. Cushing's triad involves an increased systolic blood pressure, a widened pulse pressure, bradycardia, and an abnormal respiratory pattern. In children, a slow heart rate is especially suggestive of high ICP.
Irregular respirations occur when injury to parts of the brain interfere with the respiratory drive. Cheyne-Stokes respiration, in which breathing is rapid for a period and then absent for a period, occurs because of injury to the cerebral hemispheres or diencephalon.
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