The patient is a 21 year old American Literature major who graduated from college this December. Upon graduating, he followed in the footsteps of his idol Thoreau and decided he wanted to "live simply" so he bought an old, rustic, wood-stove cabin in the woods.  He was further inspired by the #Minimalist movement that he learned about on Netflix. After one week gathering and cooking his own food in the cabin he noticed that he had a persistent headache with occasional dizziness and confusion. He's never had these symptoms before so he decided to go to the nearby ED. In the ED, he is hypertensive, tachycardic and complaining of nausea. Which of the following is true?

A. You would expect to see a Rightward shift of hemoglobin dissociation curve

B. Half-life of CO with face mask is 90 minutes

C. Headache is the most common symptom

D. A common presenting sign is skin discoloration

References:

1. Centers for Disease Control and Prevention (CDC). Carbon monoxide poisoning from hurricane-associated use of portable generators--Florida, 2004. MMWR Morb Mortal Wkly Rep 2005; 54:697.

2. Ellenhorn's Medical Toxicology: Diagnosis and Treatment of Human Poisoning, 2nd ed, Ellenhorn MJ, Schonwald S, Ordog G, Wasserberger J (Eds), Williams & Wilkins, Baltimore 1997.

3. Ernst A, Zibrak JD. Carbon monoxide poisoning. N Engl J Med 1998; 339:1603.

4. Hampson NB, Dunford RG, Kramer CC, Norkool DM. Selection criteria utilized for hyperbaric oxygen treatment of carbon monoxide poisoning. J Emerg Med 1995; 13:227.

5. Hampson NB, Dunn SL. Carbon Monoxide Poisoning from Portable Electrical Generators. J Emerg Med 2015; 49:125.

6. Harper A, Croft-Baker J. Carbon monoxide poisoning: undetected by both patients and their doctors. Age Ageing 2004; 33:105.

7. Kao LW, Nañagas KA. Carbon monoxide poisoning. Emerg Med Clin North Am 2004; 22:985.

8. Satran D, Henry CR, Adkinson C, et al. Cardiovascular manifestations of moderate to severe carbon monoxide poisoning. J Am Coll Cardiol 2005; 45:1513.

9. Thom SR, Taber RL, Mendiguren II, et al. Delayed neuropsychologic sequelae after carbon monoxide poisoning: prevention by treatment with hyperbaric oxygen. Ann Emerg Med 1995; 25:474.

10. Tomaszewski C. Carbon monoxide poisoning. Early awareness and intervention can save lives. Postgrad Med 1999; 105:39.

11. Touger M, Gallagher EJ, Tyrell J. Relationship between venous and arterial carboxyhemoglobin levels in patients with suspected carbon monoxide poisoning. Ann Emerg Med 1995; 25:481.

12. Vogel SN, Sultan TR, Ten Eyck RP. Cyanide poisoning. Clin Toxicol 1981; 18:367

13. Weaver LK. Carbon monoxide poisoning. Crit Care Clin 1999; 15:297.

Patient is a 40 year old, avid ice fisherman from Minnesota. He's been very upset by how warm the winter has been this year because the lakes haven't frozen over and he hasn't been able to ice fish. After a week long cold spell, he decided "you know what, it's probably safe out on the ice now". He couldn’t be more wrong. After getting about 10 feet out onto the lake, he fell through. He was in the water for about 5 minutes before he was able to pull himself out and walk back his car. Someone saw this happen and called paramedics who arrived and noticed that the man was slurring his speech and was slightly confused.  His temperature at the time was 30 C (91.4 F) and HR 29. He was transported to the ED where he continues to exhibit lethargy and shivering. Which of the following is true?

A. Pacing is indicated for this patient

B. Elevation of the J point is prognostic for mortality

C. Hypothermia causes shortened QT intervals on EKG

D. In severe hypothermia, extremities should be warmed first because they aren't as well perfused as the trunk

E. Allow up to 1 minute for pulse check before defibrillation

References:

1. Danzl DF, Pozos RS. Accidental hypothermia. N Engl J Med 1994; 331:1756.

2. Delaney KA, Vassallo SU, Larkin GL, Goldfrank LR. Rewarming rates in urban patients with hypothermia: prediction of underlying infection. Acad Emerg Med 2006; 13:913.

3. Graham CA, McNaughton GW, Wyatt JP. The electrocardiogram in hypothermia. Wilderness Environ Med 2001; 12:232.

4. Gentilello LM. Advances in the management of hypothermia. Surg Clin North Am 1995; 75:243.

5. Giesbrecht GG. Cold stress, near drowning and accidental hypothermia: a review. Aviat Space Environ Med 2000; 71:733.

6. Harchelroad F. Acute thermoregulatory disorders. Clin Geriatr Med 1993; 9:621.

7. Jolly BT, Ghezzi KT. Accidental hypothermia. Emerg Med Clin North Am 1992; 10:311.

8. Truhlář A, Deakin CD, Soar J, et al. European Resuscitation Council Guidelines for Resuscitation 2015: Section 4. Cardiac arrest in special circumstances. Resuscitation 2015; 95:148.

9. Walpoth BH, Walpoth-Aslan BN, Mattle HP, et al. Outcome of survivors of accidental deep hypothermia and circulatory arrest treated with extracorporeal blood warming. N Engl J Med 1997; 337:1500.

You are examining a patient who presents with EMS from home after an apparent dog bite injury. He states he spent 7 hours trying to get the “cutest” picture of his dog for reddit so he could get some reddit gold and upvotes -- but that his dog became agitated by all the picture taking and he alleges that his dog proceeded to bite him. His friend who accompanies him thinks the real reason his dog bit him is because he feeds his dog a #vegandiet and his dog has become tired of this.  

In which of the following is true?

A. Tetanus vaccination is only indicated if vaccination has not occurred in <10 years

B. Hand lacerations can be closed for cosmesis if no infection is present and if <12 hours

C. Antibiotic prophylaxis is always indicated in hand injuries

D. When closing wounds, subcutaneous sutures are preferred

E. Wound cultures should be acquired on initial ED presentation in case of infectious complication in the future.

References:

1. Aziz H, Rhee P, Pandit V, et al. The current concepts in management of animal (dog, cat, snake, scorpion) and human bite wounds. J Trauma Acute Care Surg 2015; 78:641.

2. Boenning DA, Fleisher GR, Campos JM. Dog bites in children: epidemiology, microbiology, and penicillin prophylactic therapy. Am J Emerg Med 1983; 1:17.

3. Brook I. Human and animal bite infections. J Fam Pract 1989; 28:713.

4. De Munnynck K, Van de Voorde W. Forensic approach of fatal dog attacks: a case report and literature review. Int J Legal Med 2002; 116:295.

5. Faciszewski T, Coleman DA. Human bite wounds. Hand Clin 1989; 5:561.

6. Fleisher GR. The management of bite wounds. N Engl J Med 1999; 340:138.

7. Goldstein EJ. Management of human and animal bite wounds. J Am Acad Dermatol 1989; 21:1275.

8. Kannikeswaran N, Kamat D. Mammalian bites. Clin Pediatr (Phila) 2009; 48:145.

9. Moran GJ, Talan DA. Hand infections. Emerg Med Clin North Am 1993; 11:601.

10. Phair IC, Quinton DN. Clenched fist human bite injuries. J Hand Surg Br 1989; 14:86.

11. Talan DA, Citron DM, Abrahamian FM, et al. Bacteriologic analysis of infected dog and cat bites. Emergency Medicine Animal Bite Infection Study Group. N Engl J Med 1999; 340:85.

A 57 year old male presents to the ED in December via EMS obtunded and was found unresponsive. He cannot provide any history, but EMS asks you to check his instagram because before he was found unresponsive he kept yelling out, “just made the dopest boomerang”. It turns out the patient was found walking staggeredly downtown and telling passerbys he sees “snow everywhere”.  Bystanders made an insta post of the patient making an insta post, with holiday sparkle filter and caption #catchingthechristmasspirit. However one bystander was a physician and actually decided to help. He has tremors on initial exam and borderline hypotensive.

Which of the following is correct?

A. Initially, there is a raised osmolar gap followed by anion gap elevation

B. The presence of calcium oxalate stones is specific for ethylene glycol poisoning

C. Hemodialysis is ineffective at removing methanol

D. Activated charcoal has a role if used in the initial presentation

References:

Bekka R, Borron SW, Astier A, et al. Treatment of methanol and isopropanol poisoning with intravenous fomepizole. J Toxicol Clin Toxicol 2001; 39:59.

1. Casavant MJ, Shah MN, Battels R. Does fluorescent urine indicate antifreeze ingestion by children? Pediatrics 2001; 107:113.

2. Church AS, Witting MD. Laboratory testing in ethanol, methanol, ethylene glycol, and isopropanol toxicities. J Emerg Med 1997; 15:687.

3. Hanouneh M, Chen TK. Calcium Oxalate Crystals in Ethylene Glycol Toxicity. N Engl J Med 2017; 377:1467.

4. Hoffman RS, Smilkstein MJ, Howland MA, Goldfrank LR. Osmol gaps revisited: normal values and limitations. J Toxicol Clin Toxicol 1993; 31:81

5. Höjer J. Severe metabolic acidosis in the alcoholic: differential diagnosis and management. Hum Exp Toxicol 1996; 15:482.

6. Kraut JA. Diagnosis of toxic alcohols: limitations of present methods. Clin Toxicol (Phila) 2015; 53:589.

7. Fraser AD. Clinical toxicologic implications of ethylene glycol and glycolic acid poisoning. Ther Drug Monit 2002; 24:232.

8. Kerns W 2nd, Tomaszewski C, McMartin K, et al. Formate kinetics in methanol poisoning. J Toxicol Clin Toxicol 2002; 40:137.

9. Liesivuori J, Savolainen H. Methanol and formic acid toxicity: biochemical mechanisms. Pharmacol Toxicol 1991; 69:157.

10. Moreau CL, Kerns W 2nd, Tomaszewski CA, et al. Glycolate kinetics and hemodialysis clearance in ethylene glycol poisoning. META Study Group. J Toxicol Clin Toxicol 1998; 36:659.

11. Paasma R, Hovda KE, Hassanian-Moghaddam H, et al. Risk factors related to poor outcome after methanol poisoning and the relation between outcome and antidotes--a multicenter study. Clin Toxicol (Phila) 2012; 50:823.

A 47 year old male presents to the ED from home after he was found locked in his attic. He was lethargic and unresponsive. A neighbor had not seen the patient for a few days.  The last time the neighbor saw the patient, he was told by them they weren’t feeling good, and they were going to “netflix and chill”.

Which of the following is true?

A. In adults with septic shock unresponsive to fluid therapy, IV glucocorticoids have been shown to substantially reduce mortality.

B. IV steroids should be given prior to antibiotics in those with suspected meningococcemia.

C. Steroid taper is preferred for those discharged after COPD exacerbation

D. Steroids in pediatric meningitis have been shown to reduce neurologic complications

E. The risk of adverse effects for steroids does not appear to be significant if therapy is <30 days

References:

American Academy of Pediatrics. Pneumococcal infections. In: Red Book: 2015 Report of the Committee on Infectious Diseases, 30th ed, Kimberlin DW, Brady MT, Jackson MA, Long SS (Eds), American Academy of Pediatrics, Elk Grove Village, IL 2015. P.626.

Annane D, Bellissant E, Bollaert PE, et al. Corticosteroids for treating sepsis. Cochrane Database Syst Rev 2015; :CD002243.

Annane D, Bellissant E, Bollaert PE, et al. Corticosteroids in the treatment of severe sepsis and septic shock in adults: a systematic review. JAMA 2009; 301:2362.

Brouwer MC, McIntyre P, Prasad K, van de Beek D. Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev 2015; :CD004405.

Chaudhuri A. Adjunctive dexamethasone treatment in acute bacterial meningitis. Lancet Neurol 2004; 3:54.

de Gans J, van de Beek D, European Dexamethasone in Adulthood Bacterial Meningitis Study Investigators. Dexamethasone in adults with bacterial meningitis. N Engl J Med 2002; 347:1549.

Minneci PC, Deans KJ, Eichacker PQ, Natanson C. The effects of steroids during sepsis depend on dose and severity of illness: an updated meta-analysis. Clin Microbiol Infect 2009; 15:308.

Minneci PC, Deans KJ, Natanson C. Corticosteroid therapy for severe sepsis and septic shock. JAMA 2009; 302:1643; author reply 1644.

Minneci PC, Deans KJ, Natanson C. Corticosteroid therapy for severe sepsis and septic shock. JAMA 2009; 302:1643; author reply 1644.

Mithoowani S, Gregory-Miller K, Goy J, et al. High-dose dexamethasone compared with prednisone for previously untreated primary immune thrombocytopenia: a systematic review and meta-analysis. Lancet Haematol 2016; 3:e489.

Mizutani H, Furubayashi T, Imai Y, et al. Mechanisms of corticosteroid action in immune thrombocytopenic purpura (ITP): experimental studies using ITP-prone mice, (NZW x BXSB) F1. Blood 1992; 79:942.

Sligl WI, Milner DA Jr, Sundar S, et al. Safety and efficacy of corticosteroids for the treatment of septic shock: A systematic review and meta-analysis. Clin Infect Dis 2009; 49:93.

Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 2004; 39:1267.

A 47 year old male presents after returning from a trip to Orlando. He was visiting Harry Potter World and states he had left his insulin at home and instead prescribed himself Butterbeers BID. He rode “Escape from Gringotts”, but shortly after his third ride his friend noticed his skin and facial complexion looked much worse than one of the goblins. An ambulance was called. En route the patient’s friend tweeted #HogwartsExpresss. The patient arrived tachycardic with poor capillary refill. He was lethargic and unable to provide any history and was disoriented.

Which of the following is true regarding this patient’s condition?

A. DKA has a higher mortality than HHS

B. Thromboembolic events are the most common cause of death in HHS

C. Cerebral edema is managed with prompt diuretics and steroids

D. Mental status changes are correlated with changes in serum osmolarity in HHS

References:

American Diabetes Association: Hyperglycemic crises in patients with diabetes mellitus (Position Statement). Diabetes Care 24:1988–1996, 2001

Driver BE et al. Discharge glucose is not associated with short-term adverse outcomes in emergency department patients with moderate to severe hyperglycemia. Ann Emerg Med 2016 Dec; 68:697.

Basu A, Close CF, Jenkins D, Krentz AJ, Nattrass M, Wright AD: Persisting mortality in diabetic ketoacidosis. Diabet Med 10:282–289, 1992

Bello FA, Sotos JF: Cerebral oedema in diabetic ketoacidosis in children.Lancet 336:64, 1990

Boyd JC et al. Relationship of potassium and magnesium concentrations in serum to cardiac arrhythmias. Clin Chem 1984; 30(5): 754-7. PMID: 6713638

Ennis ED, Stahl EJVB, Kreisburg RA: The hyperosmolar hyperglycemic syndrome. Diabetes Rev 2:115–126, 1994

Gerich JE, Martin MM, Recant LL: Clinical and metabolic characteristics of hyperosmolar nonketotic coma. Diabetes 20:228–238, 1971

Guisado R, Arieff AI: Neurologic manifestations of diabetic comas: correlation with biochemical alterations in the brain. Metabolism 24:665–669,1975

Kaufman FR, Halvorson M: The treatment and prevention of diabetic ketoacidosis in children and adolescents with type 1 diabetes mellitus. Pediatr Ann 28:576–582, 1999

Kitabchi AE, Ayyagari V, Guerra SMO, Medical House Staff: The efficacy of low dose versus conventional therapy of insulin for treatment of diabetic ketoacidosis.Ann Int Med 84:633–638, 1976

Kitabchi AE, Umpierrez GE, Murphy MB, Barrett EJ, Kreisberg RA, Malone JI, Wall BM: Management of hyperglycemic crises in patients with diabetes. Diabetes Care 24:31–53, 2001

Morris LR, Kitabchi AE: Efficacy of low-dose insulin therapy for severely obtunded patients in diabetic ketoacidosis. Diabetes Care 3:53–56, 1980

You are examining a 27 year old male who presents to the ED after slipping off a ledge in an elevator shaft. He was just hired on as an elevator technician and received only 1 day of formal training. He works for the silicon valley startup called “Going Up”, where they crowdsource technicians with an app. The patient slipped and fell several feet down the shaft, eventually straddling a crossbeam. He felt immediate pain and has not been able to urinate since the accident. Which of the following is true?

A. If a foley is inserted and draining urine in the setting of pelvic fracture, the foley should still be removed

B. The majority of urethral injuries are nonoperative

C. Anterior urethral injuries are commonly complicated by incontinence

D. Performing a retrograde urethrograde is always indicated in the setting of suspected urethral trauma

E. Posterior urethral injuries are most commonly secondary to pelvic fractures

References:

Gomez RG, Ceballos L, Coburn M, et al. Consensus statement on bladder injuries. BJU Int 2004; 94:27.

Haas CA, Brown SL, Spirnak JP. Limitations of routine spiral computerized tomography in the evaluation of bladder trauma. J Urol 1999; 162:51.

Hsieh CH, Chen RJ, Fang JF, et al. Diagnosis and management of bladder injury by trauma surgeons. Am J Surg 2002; 184:143.

Sklar DP, Diven B, Jones J. Incidence and magnitude of catheter-induced hematuria. Am J Emerg Med 1986;4:14–16. PMID: 3947427

Vaccaro JP, Brody JM. CT cystography in the evaluation of major bladder trauma. Radiographics 2000; 20:1373.

You are called by EMS to the bedside of a recently arrived patient who presents with shortness of breath from his home after he was attempting to have his own fireworks show. He had periscoped the event on his twitter feed with the hashtag, “waketheneighbors,  however, he had an old iPhone 5 that didn’t have a good zoom function, so he ended up being close to the fireworks as they prematurely detonated. He was knocked backwards and lost consciousness. EMS arrived and found him with headaches, tinnitus and blood from his right ear. Which of the following is true?

A. Lack of otological damage basically excludes serious blast injury to other organs

B. Steroids have been shown to reduce mortality from pulmonary blast injury

C. Lung contusions are the most common form of lung injury

D. Tertiary blast wave injury is the most common cause of death.

References:

Avidan V, Hersch M, Armon Y, Spira R, Aharoni D, Reissman P et al. Blast lung injury: clinical manifestations, treatment, and outcome. Am J Surg 2005; 190(6):927-931

DePalma RG, Burris DG, Champion HR, Hodgson MJ. Blast Injuries. The New England Journal of Medicine 352, 1335-1342. 2005. Ref Type: Generic

Harrisson SE, Kirkman E, Mahoney P. Lessons Learnt from Explosive Attacks. JR Army Med Corps 153[4], 278-282. Ref Type: Generic

Horrocks CL. Blast Injuries: Biophysics, Pathophysiology and Management Principles. JR Army Med Corps 147, 28-40. 2001. Ref Type: Generic

Kizer KW. Dysbarism. In: Tintinalli JE, Kelen GD, Stpczynski JS, editors. Emergency Medicine: A Comprehensive Study Guide 6th edition. 5th ed. Maidenhead: McGraw-Hill; 2003. 1269-1278.

Leibovici D, Gofrit ON, Shapira SC. Eardrum perforation in explosion survivors: is it a marker of pulmonary blast injury? Ann Emerg Med 1999; 34(2):168-172.

Sasser SM, Sattin RW, Hunt RC, Krohmer J. Blast lung injury. Prehosp Emerg Care 2006; 10(2):165-172.

A 18 year old African American male with history of sickle cell disease presents to the ED with severe chest pain. He is a student at the Juilliard school and was playing the clarinet -- but unfortunately the opera house they were performing in had the airconditioning break. He was sweating a lot and didn't drink much water. By the end of the show, he was exhausted and began having severe chest pain and shortness of breath. He presented to the ED where he was tachycardic to 110, tachypnea, hypertensive to 145/90 and a temp to 101.4. You ask him how he feels and says in broken sentences and in varying levels of consciousness, “palms sweaty, knees weak, arms are heavy” and his saturation is 75%. Which of the following is correct?

A. Aggressive fluid hydration is indicated in these scenarios due to risk of systemic infection

B. Acute chest syndrome is the second most common cause of death in sickle cell disease patients behind splenic rupture.

C. Atypical bacteria are the most common bacterial infection in acute chest syndrome.

D. In severe acute chest syndrome, exchange transfusions are always performed after simple blood transfusions

E. Acute chest syndrome is defined as chest pain in a patient with sickle cell disease

Resources:

Field JJ, DeBaun MR. Acute chest syndrome in adults with sickle cell disease. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2018

Howard, Jo, Hart, Nicholas, Roberts-Harewood, Marilyn, Cummins, Michelle, Awogbade, Moji, Davis, Bernard; “Guideline on the management of acute chest syndrome in sickle cell disease”. BCSH Committee, 30 March 2015. https://doi.org/10.1111/bjh.13348

Vichinsky E, Neumayr L, Earles A, Williams R, Lennette E, et al. Causes and outcomes of the acute chest syndrome in sickle cell disease. N Engl J Med. 2000; 342:1855-1865.

You are working with EMS at a Billy Joel concert. It’s a pretty tame evening and you resort to standing in behind stage and eyeing the crowd. As Billy Joel plays Piano Man. One man clutches his chest and looks up to the sky as if to break out in song with the famed Piano Man. However he doesn’t, and instead drops to the ground and does not move. His girlfriend is super impressed and thinks he was overwhelmed with emotion, and makes an instagram story out of the incident.  Fortunately, one of her “live followers”, is a nurse and urgently called her to intervene and call for help. You rush to the patient with your team and find him with thready pulses and unresponsive. Rhythm strip shows a wide complex, regular tachycardia. Which of the following is true?

A. In patients with ischemic cardiac history, procainamide has displayed fastest rate of conversion

B. SVT with aberrancy can be mistaken for VT in up to 20% of adult patients

C. Nonsustained VT is a predictor of sudden cardiac death

D. Faster rate VT should suggest toxicologic cause

——- References:

Brugada P et al. A new approach to the diagnosis of regular wide complex tachycardia. Circulation 1991; 83: 1649-59. PMID: 2022022

Hollowell H et al. Wide-complex tachycardia: beyond the traditional differential diagnosis of ventricular tachycardia vs supra ventricular tachycardia with aberrant conduction. Am J Emerg Med 2005; 23: 876-89. PMID: 16291445

Ortiz M et al. Randomized comparison of intravenous procainamide vs. intravenous amiodarone for the acute treatment of tolerated wide QRS tachycardia: the PROCAMIO study. Eur Heart J 2016. PMID: 23754046

Yealy D, Kosowsky JM: Dysrhythmias, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 79: p 1034-63.

You are examining a 15 year old who presents to the ED with his Mother after developing hand pain 2 hours prior. He is a proud member of the local paintball team “SLY Slytherins”. You observe an uninterested teenager texting on his phone and sweeping his long hair of his face every so often to see his text messages. Suddenly he starts waving his phone at you in sweeping motions -- when you ask him why, he states, “It’s for my SNAP story brah”. His Mother states she thinks he was cleaning his paintball gun a few hours earlier today. On exam there is full range of motion and local, exquisite pain in the palmar aspect of the hand near the hypothenar eminence. No swelling, warmth, or exudate is noted. Which of the following is true?

A. X-ray is very poor at showing foreign body material

B. Physical exam plays an integral role in identifying extent of injury

C. Amputation risk on average is less than 50% in these patients

D. QT prolongation is a useful marker in hydrofluoric acid exposure

——-References:

Hart, R. et.al. (2001). Emergency and Primary Care of The Hand. American College of Emergency Physicians.

Loveday, I. (2007). High-pressure injection injuries. Emergency Nurse. PMID: 18065043

Locker, J. & Carstens, A. (2010). High-pressure injection of silica-based paint into a finger. The New Zealand Medical Journal. PMID: 20648104

Kohli, N. (2009). High-pressure injection injury in a furniture repairman -an outwardly minor in jury with the potential for a devastating outcome. Journal of Occupational and Environmental Medicine. PMID: 19741372

A 36 year old female from Wisconsin presents to the ED for abdominal pain. It's late summer and she is really excited to take her 2 children to the Minnesota State Fair (the 2nd largest state fair in the country) over memorial day weekend to enjoy favorites like turkey legs, Sweet Martha's Cookies and battered deep-fried snickers on a stick. Like the other 2 million people there, she attends the fair and chows down. 30 minutes after eating her deep-fried snickers on a stick, she begins having some cramping abdominal pain on her right side. It has happened before, but usually goes away. After 2 days or so of this pain, she decides to go to an urgent care because it has made her real nauseous and caused her to vomit. On exam, she is febrile and BP 90/70. She is extremely uncomfortable. A RUQ US is performed but the report states it is limited due to “overlying bowel gas”. Which of the following is correct?

A) Elevations in ALT and AST are common in cholecystitis

B) This patient should undergo emergent cholecystectomy
C) Patients with biliary colic should be made NPO and treated with IVF and IV Abx
D) Piperacillin-tazobactam is the Antibiotic of choice for biliary pathology requiring surgery

E) Physical exam findings are sufficient to establish the diagnosis of cholecystitis

——-References:

Williams, D. Gallbladder. Retrieved September 16, 2018, from https://onlinemeded.org/spa/gastroenterology/gallbladder/

Zakko, SF, Afdhal, NH. Acute Cholecystitis: Pathogenesis, clinical features, and diagnosis. UpToDate.Waltham, MA: UpToDate Inc. https://www.uptodate.com/contents/acute-cholecystitis-pathogenesis-clinical-features-and-diagnosis (Accessed on September 17, 2018.)
Zakko, SF. Overview of gallstone disease in adults. UpToDate.Waltham, MA: UpToDate Inc. https://www.uptodate.com/contents/overview-of-gallstone-disease-in-adults (Accessed on September 17, 2018.)

A 37 year old woman presents with concern for a bite. She collects caterpillars for her hobby and takes a particular liking to pink fuzzy ones. She was hiking in near her lake house and when she returned home she noticed a rash on her RLQ of her abdomen. She posted the photo to instagram as #trueblood and #oncebitten, however it was too painful to touch and none of her followers offered any medical advice so she presented to the ED for further evaluation. She also added #blessed, but still no advice.

Which of the following is true?

A. Acute prophylactic management does not effectively prevent cardiac manifestations

B. The majority of patients recall being bite by a tick

C. Lyme disease manifests as arthritis within the first 2 weeks of infection

D. Amoxicillin and Doxycycline have equal efficacy for early localized disease

E. Serologic testing is often false positive during the first two weeks

——-References:

Hu LT. In the clinic. Lyme disease. Ann Intern Med 2012; 157:ITC2.

Logigian EL, Kaplan RF, Steere AC. Chronic neurologic manifestations of Lyme disease. N Engl J Med 1990; 323:1438.

Nadelman RB, Nowakowski J, Forseter G, et al. The clinical spectrum of early Lyme borreliosis in patients with culture-confirmed erythema migrans. Am J Med 1996; 100:502.

Steere, A C (1987). "The clinical evolution of Lyme arthritis.". Annals of internal medicine, 107 (5), p. 725.

Steere, A. C., M.D. (1989). Lyme disease. The New England Journal of Medicine, 321(9), 586-596. doi:http://dx.doi.org.go.libproxy.wakehealth.edu/10.1056/NEJM198908313210906

Steere AC, McHugh G, Damle N, Sikand VK. Prospective study of serologic tests for lyme disease. Clin Infect Dis 2008; 47:188.

Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2006; 43:1089.

A 22 yo male presents septic to the ED 2 hours ago. He has been out of insulin for a few days now because he has been playing fortnite and after making a bunch of in-app purchases, he optimized his avatar and went on a crazy battle royale spree.  His battle royale spree ended when he was found by EMS surrounded by vomit at home.

His blood pressure on arrival is 85/60, and he is tachycardic at 110. ABG shows pH of 7.25, pCO2 of 26 mmHg and lactate of 3.5. You want to give the patient fluids, what would you like to give?

A) 2 more liters of normal saline

B) D5 to raise his glucose level

C) Lactated Ringers

D) Free water

The parents of a 11 year old are bringing in their son due to tremors. He was watching videos of the popular youtuber, PewDiePie(pronounced Puudeepie), when he stumbled upon some sort of Monster Energy drink challenge video.  He subsequently ingested 4 cans of Monster in one hour after he watched the video and is now in your ER.. The parents state he has no medical history other than ADHD for which he is on 2 different medications for. His vitals are within normal range yet he states he is jittery. Further, he is now dancing and doing the Drake, "In My Feelings" challenge and recording it for his VLOG. A 12-lead EKG is performed in between his gyrations. Which of the following is true?

A. T wave inversion implies myocarditis in children in the precordial leads

B. Right axis deviation in infants is an expected finding

C. All conduction intervals are longer in children due to immature neural connections

D. R wave dominance in infancy carries an ominous prognosis

E. The most common cause of wide complex tachycardia in children is ventricular tachycardia

A 21 year old male presents to the ED after he fell playing basketball. He states he was reenacting the final game of Kobe Bryant’s NBA career, and after shooting so many times (because this is after all Kobe Bryant), he was attempting his 26th layup when he felt sudden pain and fell, getting dirt from the side court all over his recently signed Kobe Bryant Lakers jersey. He arrives to the ED in extreme right shoulder pain with stable vitals and right arm abrasions. Which of the following is true?

A. Posterior dislocations have a higher risk of neurological deficit

B. Axillary nerve deficit is most commonly found in posterior dislocations

C. Posterior dislocation can be effectively ruled out if the patient can perform external rotation

D. The ability to touch the opposite shoulder does not rule out anterior dislocation

EMS arrives with a 29 year old male who was involved in a head on collision on the interstate. He was in a high speed car chase in which he was running from the law after what he said was a “misunderstanding” at a bank. He states aliens told him they needed to borrow money, and he was simply trying to help them out. The misunderstanding involved the stealing of $5,000 dollars in gold Gringotts Galleons coins. He states he is a collector of memorabilia and wanted to add to his coin counts. He crashed into a semi in oncoming traffic.

On initial evaluation the patient was alert, talking, and had bilateral breath sounds. 2 IV’s are placed. His initial blood pressure is 87/57. Which the following is true?

A. Sensitivity decreases with Trendelenburg with the FAST exam

B. The FAST exam has higher specificity than sensitivity

C. Performing the FAST increases time it takes to go to the OR

D. In penetrating trauma, RUQ view should be obtained first

E. Direct peritoneal lavage is less sensitive than the FAST exam

A 58 year old survivalist is patrolling his property when he decided to take a lunch break for his MRE which he packed in his bunker. He recently purchased the fully-furnished bunker in the Mojave desert after he was watching Youtube Videos of Alex Jones yelling on his Drudge Report sponsored InfoWars show.  He is also a frequently reader of Drudge Report and participates actively on commenting on their linked sites. After sitting down on his lunch break to type another comment on a blog, he he states he was bitten by a snake. He does not recall what it looked like. He arrives to your ED via ranger patrol with stable vital signs, redness and swelling are present at the site. Which of the following is true?

A. Dosing of immune fab is same as in adults as in children

B. The immune fab used has a significant risk of anaphylaxis

C. Prophylactic antibiotics are indicated upon discharge

D. Immune Fab has no effect on coral snake envenomation

E. Envenomation is much less common than dry bites

A nervous 14 year old male presents to the ED with his mother. The patient has been secretly dating a girl at his high school and they met under the bleachers last week where he received his first kiss to the hit tune, “Can you feel the love tonight” (Lion King version). His girlfriend, who he refers to affectionately as Nala, requested that particular song play and she wore a t-shirt that said “Hakuna Matata”. They have been pecking each other daily since then. They are not sexually active. His girlfriend was diagnosed with seropositive streptococcal meningitis 2 days ago and was admitted to your hospital for further management. On exam the patient has facial acne, thick eyeglasses, wears a shirt that says “I never recieved my acceptance letter to Hogwarts”, but otherwise appears healthy. He is afebrile with normal vital signs. Which of the following is true regarding chemoprophylaxis?

A. Chemoprophylaxis is indicated in this case

B. Rifampicin is preferred in those on birth control

C. All healthcare workers meet criteria for chemoprophylaxis if involved in the patient’s care

D. Ceftriaxone is preferred in pregnant patients

A 27 year old male was reading a Benjamin Franklin biography and watching the famous Movie Jackass as well. Unfortunately, he became inspired by both at the same time -- and recreated Benjamin Franklin’s famous kite experiment. In the process of recreating the experiment, he was struck by lightning -- he had a significant amount of metal earrings on that EMS suspects might have contributed to this. Which of the following is true?

A. Blood is the path of least resistance for electricity to move through

B.  Ventricular fibrillation is the most common cause of cardiac arrest

C. Keraunoparalysis is most often transient and does not require treatment

D. Troponins have prognostic utility for determining admission

E. Victims can benefit from prolonged CPR