Provided by PEER VIII. PEER (Physician’s Evaluation and Educational Review in Emergency Medicine) is ACEP’s gold standard in self-assessment and educational review. These questions are from the latest edition of PEER—PEER VIII, which made its debut at ACEP’s 2011 Scientific Assembly. To learn more about PEER VIII, or to order it, go to www.acep.org/bookstore.
1. Which of the following statements regarding a patient with fever is correct?
A. Bradycardia with a fever can occur in Lyme disease
B. Chills occur in response to a declining body temperature
C. Heart rate increases by 30 beats/min for each 0.55°C rise in temperature
D. Rectal temperatures are typically 2°C higher than oral temperatures
2. A 60-year-old man with a history of alcohol abuse presents with epigastric pain. Initial laboratory test results are as follows: WBC count, 20,000 cells/mcL; blood glucose, 450 mg/dL; AST, 375 IU/L; and lipase, 400 U/L. What is the appropriate disposition?
A. General medical floor
C. Observation unit
D. Surgical floor
3. Which of the following statements regarding closure of scalp lacerations is correct?
A. Blindly clamping a vessel is the best way to gain control of active bleeding
B. Complications of scalp wound infection include osteomyelitis and brain abscess
C. Hair should be shaved prior to suturing or stapling a scalp wound
D. Hair should not be washed for 24 to 48 hours after wound closure
4. Which of the following pairings of murmur and underlying cause is correct?
A. Diastolic murmur that radiates to the carotid—mitral regurgitation
B. Short, soft diastolic murmur—aortic regurgitation
C. Systolic murmur that radiates to the axilla—aortic stenosis
D. Systolic murmur that radiates to the axilla—mitral stenosis
5. In a previously healthy patient with severe pneumonia who is awaiting admission to the ICU, which of the following antibiotic regimens should be started in the emergency department?
A. Ampicillin-sulbactam and vancomycin
B. Azithromycin and levofloxacin
C. Ceftriaxone and levofloxacin
D. Ertapenem and vancomycin
- The answer is A, Bradycardia with a fever can occur in Lyme disease.
(Marx, 83-86; Tintinalli, 1042-1044, 1082-1088)
Although an elevated body temperature is typically associated with tachycardia, there are certain disease processes that produce a relative bradycardia, such as the concomitant use of beta-blockers, or even an overt bradycardia. Overt bradycardia in association with a fever is classically described with infection and inflammation of the cardiac structures themselves, including Lyme disease, endocarditis, and rheumatic fever. Rectal temperatures are often 0.7 to 1°C higher than oral temperatures. Axillary and tympanic temperatures are quite variable and cannot be reliably related to a core temperature measurement. In adult patients, the heart rate can increase by 10 beats/min for each 0.55°C rise in temperature; the respiratory rate can increase by 2 to 4 breaths/min per 1°C rise in temperature. Chills occur when a fever causes the hypothalamus to reset the thermostatic normal to a higher temperature. Since the body temperature is low, the patient shivers or has chills until the body temperature is raised to this new febrile level as set by the hypothalamus. Sweating occurs as the patient’s fever declines.
- The answer is B, ICU.
(Marx, 1172-1180; Tintinalli, 558-562)
Using the Ranson criteria, a patient with a WBC count of 20,000 cells/mcL, blood glucose level of 450 mg/dL, and AST 375 IU/L is classified as having severe pancreatitis, with a predicted mortality rate of at least 15%, necessitating admission to an ICU. The Ranson criteria are used to predict mortality associated with pancreatitis. At the time of admission, points are given for age older than 55, WBC count greater than 16,000 cells/mcL, glucose greater than 200 mg/dL, LDH greater than 350 IU/L, and AST greater than 250 U/L. Additional points are calculated during the first 48 hours of admission and then tabulated. A score of 3 or more is associated with at least a 15% mortality rate and indicates the need for admission to the ICU. This patient already has a Ranson score of 4. A general medical admission, surgical floor admission, or observation unit admission is inappropriate in light of the high mortality. Monitoring in an ICU is indicated in most patients with severe pancreatitis who have no indication for surgical management. Pancreatitis is typically caused by gallstone ductal obstruction or alcohol abuse. Pancreatic ductal obstruction increases the pressure on pancreatic enzymes, while alcohol abuse has a direct toxic effect. Both result in premature activation of trypsinogen and zymogen within the pancreas and subsequent autodigestion. Patients typically present with epigastric pain that radiates to the back along with nausea and vomiting; they are often afebrile. Serum lipase level has a higher sensitivity and specificity than serum amylase when diagnosing pancreatitis but has no correlation with morbidity or mortality rates.
- The answer is B, Complications of scalp wound infection include osteomyelitis and brain abscess.
(Laughlin, 126-128; Marx, 703-711; Roberts, 623-625)When scalp lacerations involve the galea aponeurotica, bacteria can penetrate the layer of loose connective tissue beneath it, gaining access to the venous sinuses of the brain. A wound infection can therefore cause osteomyelitis, meningitis, or brain abscess. It is of utmost importance to make sure that all foreign bodies are removed and that cautious and conservative debridement is performed prior to closure of the galea and superficial layers of the wound to avoid this complication. It is controversial whether the galea should be closed as a separate layer or whether it can be closed along with the superficial layers of the wound. Blindly clamping bleeding vessels is unlikely to be helpful in gaining control of bleeding. Using Raney clips and administering an anesthetic agent with added epinephrine are helpful in controlling active bleeding. Hair may be washed a few hours after closure; the patient does not need to wait 24 to 48 hours to remove remaining blood and debris. Although care should be taken to avoid getting hair in the wound, in most cases shaving is unnecessary. Hair can be removed by clipping around the wound or moved out of the way using a petroleum-based antibiotic ointment or tape.
- The answer is B, Short, soft diastolic murmur—aortic regurgitation.
(Marx, 1072-1074; Tintinalli, 415-423)
Murmurs are described based on the following features:
• Intensity, from barely audible in a quiet room (= 1) to heard without the stethoscope (= 6)
• Timing, systole or diastole
• Location on the chest at which best heard
• Shape, crescendo or decrescendo, and so on
• Pitch, harsh, blowing, or rumbling, and so on
• Presence or absence of radiation
Mitral stenosis classically presents with a loud S1 and an opening snap in early diastole (just after S2), with a low-pitched, rumbling mid-diastolic apical murmur. Aortic regurgitation is described as a soft early diastolic, decrescendo murmur heard best at the left upper sternal border with the patient leaning forward. It is often associated with a widened pulse pressure and can be associated with a rapidly rising and falling carotid pulse, spontaneous nail bed pulsations, and a to-and-fro murmur over the femoral artery. Mitral regurgitation classically presents as a blowing holosystolic murmur that radiates to the axilla. It is best heard with the bell when the patient is in the left lateral decubitus position. Patients with aortic stenosis classically have a harsh crescendo-decrescendo systolic murmur heard best at the right second intercostal space that radiates to the carotids and is associated with an S4 gallop. In comparison, ventricular septal defects have a characteristic loud, harsh, blowing holosystolic murmur heard best over the lower left sternal border (third or fourth intercostal spaces); when large, they can be accompanied by a displaced point of maximal impulse and a palpable thrill.
- The answer is C, Ceftriaxone and levofloxacin.
(Mandell, S27-S72; Tintinalli, 479-486)
Severe community-acquired pneumonia requiring ICU admission requires broad antibiotic coverage against Streptococcus pneumoniae and Legionella. Double antipneumococcal coverage in severe pneumonia has been shown to improve outcome. The use of a beta-lactam (ceftriaxone) and a respiratory fluoroquinolone (levofloxacin) meets this goal. Selection of appropriate antibiotic coverage is part of the Centers for Medicare & Medicaid Services (CMS) core measures design to improve patient care. Vancomycin provides excellent coverage against Staphylococcus and Streptococcus but does not cover Legionella or Pseudomonas. The addition of vancomycin is suggested if methicillin-resistant Staphylococcus aureus is a concern as part of good clinical care, but it is not part of the 2010 CMS guidelines. Azithromycin and levofloxacin cover atypical pathogens like Legionella, but azithromycin, which is a macrolide, does not provide the same antipneumococcal coverage that a beta-lactam does. Common beta-lactams include ceftriaxone, cefotaxime, ampicillin-sulbactam, and ertapenem. Levofloxacin also has the advantage of providing coverage against Pseudomonas as well as Legionella and Pneumococcus. If Pseudomonas is suspected, an antipseudomonal beta-lactam like cefepime, imipenem, meropenem, or piperacillin-tazobactam should be used in combination with levofloxacin.