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B. neuroleptic malignant syndrome

The answer is B. Neuroleptic malignant syndrome (NMS) is an idiosyncratic, life-threatening reaction to antipsychotic medications, with haloperidol being the most common cause. It is characterized by elevated temperatures, "lead pipe" muscle rigidity, altered mental status, choreoathetosis, tremors, and autonomic dysfunction (e.g., diaphoresis, labile blood pressure, incontinence, dysrhythmias). While this patient's temperature is only 102.7, students should note that any patients with temperatures greater than 105 most likely have non-infectious etiologies for temperature elevation. NMS is thought to be due to too much D2 blockade in the substantia nigra and hypothalamus. Treatment consists of stopping the causative agent and providing supportive care. Medications such as dantrolene, bromocriptine, amantadine, and lorazepam are also often used. Tardive dyskinesia (choice A) is a chronic movement disorder that results from prolonged use of antipsychotics and can include involuntary and periodic movements of the tongue or lips, mouth puckering, or flailing movements either of the extremities or of the spine. Neuroleptic-induced acute dystonia (choice C) is an acute spasm of a muscle or muscle group associated with the use of antipsychotic agents. It presents with patients complaining of neck twisting (torticollis), fixed upper gaze, facial muscle spasms, or dysarthria from tongue protrusions. In a similar family with dystonia, neuroleptic-induced akathisia (choice D) is an extrapyramidal syndrome that is manifest by agitation and restlessness. Schizophrenia, catatonic type (choice B), a diagnosis of exclusion, usually does not present with this degree of impairment.
E. Call cardiology for a decision between thrombolytic and percutaneous coronary intervention.

The answer is E. This patient is having an acute myocardial infarction. AMI is defined when two of the following three findings are present: clinical history of chest pain of at least 20 minutes duration, EKG changes and/or positive myocardial enzyme testing. This patient has ST elevation with concomitant ST depression in contiguous leads with chest pain. She needs immediate thrombolytic therapy or cardiac catheterization; if percutaneous coronary intervention (PCI) can be achieved within 90-120 minutes of emergency department arrival, the literature supports its selection over thrombolytic therapy as primary intervention. In preparation for either thrombolytic therapy or PCI, you need to control her pain, maximize O2 delivery, decrease work of the heart and inhibit platelet function. O2, nitroglycerin and morphine will increase O2 delivery to the heart. A beta blocker, which should also be administered to AMI patients who lack contraindications, will decrease the work of the heart, and aspirin will inhibit platelets. A glycoprotein IIb/IIIa-inhibitor should also be administered - selections will depend on the exact treatment course chosen for the patient. Anticoagulation with low molecular weight heparin or unfractionated heparin (dose being dependent on exact treatment course for patient) should be started if there are no patient historical or chest X-ray findings suggestive of aortic dissection.
-- For further reading, see Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th edition, pages 1011-1052; 170.
D. smallpox

The answer is D. The clinical presentation is more consistent with smallpox than any of the other etiologies. Insect bites may have been possible with the initial skin presentation but are much less likely given the spread of the process and the other symptoms. Erythema multiforme is rendered unlikely by the absence of drug ingestion. With chickenpox, fever occurs with the onset of the rash, which is characterized by simultaneous existence of individual lesions at differing stages. Also with chickenpox, the eruption is concentrated over the torso, and given the time course of this example, crusting should have been present if the patient had chickenpox.

Since smallpox has been eradicated worldwide, any cases that do occur (e.g. secondary to terrorist activity) are likely to be misdiagnosed as clinicians are unfamiliar with the disease. After a mean incubation period of 1.5-2 weeks, there is a 2-3 day prodromal phase characterized by abrupt onset of severe headache, backache, and fever. The temperature subsides over 2-3 days. An enanthema over the tongue, mouth, and oropharynx precedes the skin rash by a day. The skin rash begins as small, reddish macules, which become papules with a diameter of 2 to 3 mm over a period of one or two days; after an additional 1-2 days, the papules become vesicles with a diameter of 2 to 5 mm. The lesions occur first on the face and extremities but gradually spread to cover the body. Pustules that are 4 to 6 mm in diameter develop about four to seven days after the onset of the rash and remain for five to eight days, followed by umbilication and crusting. As occurred in this example case, there may be a second, less pronounced temperature spike five to eight days after the onset of the rash, especially if the patient has a secondary bacterial infection. Smallpox lesions have a peripheral or centrifugal distribution and are generally all at the same stage of development. Death from smallpox is ascribed to toxemia, associated with immune complexes, and to hypotension.
D. Removal of the foreign body with a moistened cotton swab
The answer is D. The cornea is one of the most sensitive parts of the body.
Tiny foreign bodies (such as the one in the Figure) lying on the surface of the cornea or on the underside of the eyelids can cause tremendous discomfort as they stimulate thousands of corneal nerve fibers with each blink. The patient may not see the foreign body but will complain of tearing and conjunctival reddening.
It is important to differentiate between intraocular and extraocular foreign bodies.
Intraocular foreign bodies (those that penetrate the globe) may diminish visual acuity by distorting the lens or by causing a vitreal hemorrhage. Extraocular foreign bodies are unlikely to diminish visual acuity unless they lie directly in the visual axis (in line with the pupil). In either case, the patient presenting to the emergency department with a suspected ocular foreign body should receive an eye examination that includes testing of visual acuity while the patient wears corrective lenses (not contact lenses).

The proper management of a suspected foreign body includes eversion of both
lids, which in this case, resulted in identification of the foreign body. A moistened cotton swab easily removes a foreign body on the palpebral conjunctiva. Fluorescein should then be applied to the cornea. Using a magnifying glass or a slit lamp, examine the cornea for epithelial defects. If a corneal abrasion is identified, the patient should refrain from wearing contact lenses until it has healed. Wearing contact lenses over a corneal epithelial defect predisposes the patient to forming an infectious corneal ulcer. There is no need to patch the eye because patching confers no benefit in healing corneal abrasions.
C. Order a venogram to rule out a deep venous thrombosis

The answer is B. Complex regional pain syndrome type I (CRPS-I), replacing the term Reflex Sympathetic Dystrophy (RSD), has been used to describe pain syndromes that sometime follow fractures, orthopedic surgery, soft tissue injuries, and even unrecognized insults to the limbs and appendages. The sympathetic nervous system appears to play a role in the maintenance of the symptoms in some, but not all, patients. It develops after an initiating noxious event, extends beyond the distribution of a single peripheral nerve, and is usually disproportionate to the inciting event. The site is most often the distal end of the affected extremity, with a distal-to-proximal gradient. It is associated with edema, changes in blood flow to the skin, abnormal sudomotor (sweat gland stimulation) activity in the region of the pain, allodynia (pain resulting from non-noxious stimulation to the skin), hyperpathia (pain persisting or increasing after mild or light pressure), or hyperalgesia. The presence of a condition that otherwise would explain the degree of pain and dysfunction excludes the diagnosis of CRPS-I. The definition of CRPS-II is the same as for CRPS-I except that there is demonstrable peripheral nerve injury. If you were concerned about osteomyelitis you would order a bone scan or MRI (B). If you were concerned about a DVT, you would first order a venous doppler of the involved extremity (C). A femoral nerve block (D) might help with his pain but is not the most appropriate course of action.
--For further reading, see Rosen's Emergency Medicine: Concepts and Clinical
Practice, 7th edition, pages 479, 2417.