A 23 year old male returns from a beach vacation, where he sustained a cut to his foot while wading. The cut wasn’t treated when it happened, and it is healing, but he says that it feels like something in the wound is “poking” him.
Of the following, which one would most likely be visible on plain film radiography?
Correct Answer D: Almost all glass is visible on radiographs if it is 2 mm or larger, and contrary to popular-belief, it doesn’t have to contain lead to be visible on plain films. Many common or highly reactive materials, such as wood, thorns, cactus spines, some fish bones, other organic matter, and most plastics, are not visible on plain films. However, the spines of the crown-of-thorns starfish or sea urchin spines contain calcium carbonate and hence are visible on plain radiographs.
A 27-year-old white male presents to the emergency department 2 hours after being bitten by a rattlesnake. He complains of weakness, abdominal cramping, left leg pain, and left leg swelling. His speech is slurred, and his breath smells of alcohol.
Physical Findings:
Which one of the following therapeutic interventions is indicated at this time?
Correct Answer A: This patient presents with a history of snakebite, swelling of an entire extremity, weakness, and ecchymosis. This is consistent with a grade III envenomation and merits antivenin therapy. Horse-serum antivenin has been available since the 1950s. More recent antivenom, CroFab, is purer and has improved properties.The old antivenin may still be available, but it is generally recommended to use the more specific and purified drug. Even with the newer agent, one must remember while the antivenin may be life saving, it also may lead to immediate hypersensitivity (anaphylaxis) and delayed hypersensitivity (serum sickness) reactions and must be used with caution.
→ Venom extractors (choice B) are thought to be useful only in the first few minutes after a bite. Two hours is too late to be of any use.
→ Tourniquets (choice C) should not be used, they have been associated with loss of limb.
→ Fasciotomy (choice D) is indicated when compartment syndrome develops. No skin tightness, no paresthesias, no poikilothermia, no pulselessness are evident in this patient.
→ Administration of platelets and fresh frozen plasma (choice E) is incorrect. Bleeding and clotting disturbances usually respond satisfactorily to treatment with specific antivenom. Fresh frozen plasma is given in cases of severe bleeding despite appropriate administration of antivenin therapy.
Key Point: Anti-venin therapy is the appropriate initial treatment in a patient who presents 2-6 hours after snake bit.
In adults, which one of the following is the most likely cause of chronic unilateral nasal obstruction?
Correct Answer A: The most common cause of nasal obstruction in all age groups is the common cold, which is classified as mucosal disease. Anatomic abnormalities, however, are the most frequent cause of constant unilateral obstruction. Of these, septal deviation is the most common. Foreign body impaction is an important, but infrequent, cause of unilateral obstruction and purulent rhinorrhea. Mucosal disease is usually bilateral and intermittent. Adenoidal hypertrophy is the most common tumor or growth to cause nasal obstruction, followed by nasal polyps, but both are less frequent than true anatomic causes of constant obstruction.
A 55 year old white male smoker has had daily severe gastroesophageal reflux symptoms unrelieved by intensive medical therapy with proton pump inhibitors. A recent biopsy performed during upper endoscopy identified Barrett’s esophagus.
Which one of the following is true about this condition?
Correct Answer D: Barrett’s esophagus is an acquired intestinal metaplasia of the distal esophagus associated with longstanding gastroesophageal acid reflux, although a quarter of patients with Barrett’s esophagus have no reflux symptoms. It is more common in white and Hispanic men over 50 with longstanding severe reflux symptoms, and possible risk factors include obesity and tobacco use. It is a risk factor for adenocarcinoma of the esophagus, with a rate of about one case in every 200 patients with Barrett’s esophagus per year. Treatment is directed at reducing reflux, thus reducing symptoms. Neither medical nor surgical treatment has been shown to reduce the carcinoma risk. One reasonable screening suggestion is to perform esophagoduodenoscopy in all men over 50 with gastroesophageal reflux disease (GERD), but these recommendations are based only on expert opinion (level C evidence), and no outcomes-based guidelines are available.
A 72-year-old male has had persistent interscapular pain with movement since rebuilding his deck 1 week ago. He rates the pain as 6 on a 10-point scale. A chest radiograph shows a thoracic vertebral compression fracture.
Which one of the following would be most appropriate at this point?
Correct Answer B: This patient has suffered a thoracic vertebral compression fracture. Most can be managed conservatively with decreased activity until the pain is tolerable, possibly followed by some bracing. Vertebroplasty is an option when the pain is not improved in 2 weeks. Complete bed rest is unnecessary and could lead to complications. Physical therapy is not indicated, and NSAIDs should be used with caution.
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