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SAEM - Environment and Endocrine
Terms in this set (30)
With respect to laboratory findings in diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar nonketotic coma (HHNC), all of the following guidelines are generally true EXCEPT:
A. BUN is elevated more in patients with HHNC (>50 mg/dL) than in patients with DKA (25-50 mg/dL).
B. Serum bicarbonate is typically severely low (<10mEq) in patients with either DKA or HHNC.
C. Serum ketones are present in patients with DKA but not usually in patients with HHNC.
D. Patients with HHNC typically have blood glucose > 700 mg/dL, whereas patients with DKA have blood glucose > 350 mg/dL.
E. Serum osmolality in patients with HHNC is typically > 350 mOsm/L.
The answer is B. Although patients with DKA typically have profound metabolic acidosis with serum bicarbonate < 10mEq, acidosis is typically absent in patients with HHNC and serum bicarbonate is usually > 15 mEq.
In a 70kg male DKA patient with serum glucose of 573 mg/dL, all of the following statements with regard to fluid and electrolyte imbalances are true EXCEPT:
A. A normal magnesium level is reassuring and obviates the need for magnesium replacement.
B. Despite a serum potassium level of 4.8 mEq, the patient is probably total body potassium depleted.
C. The patient is likely to be total body phosphorus depleted.
D. Serum sodium of 129 mEq represents dilutional hyponatremia and the corrected value is approximately 137 mEq.
E. Total body water deficit is approximately 5L.
The answer is A. Patients with DKA are typically severely dehydrated with a total body water deficit of approximately 70-80 mL/kg, in addition to being total body depleted of potassium, magnesium, and phosphorous despite initially normal serum levels of these electrolytes.
Regarding the treatment of hyperosmolar hypertonic nonketotic coma (HHNC) and its associated symptoms, which of the following is correct:
A. Phenytoin (Dilantin) is often ineffective for seizures associated with HHNC.
B. Half of the fluid deficit should be corrected over the first hour and the remainder over the following 8 hours.
C. Since patients are not acidotic, close monitoring of glucose is not necessary.
D. Hyperosmolarity should be corrected within the first few hours in the emergency department.
E. In HHNC patients with severe dehydration, bleeding diathesis is a major clinical concern.
The answer is A. Phenytoin (Dilantin) is contraindicated in patients with HHNC as it may impair endogenous insulin release and is often ineffective in the management of seizures associated with HHNC. Half of the fluid deficit should be replaced over the first 8 hours, and the remainder over the ensuing 24 hours. Glucose must be tightly monitored as fluid resuscitation alone may normalize serum glucose or precipitate hypoglycemia in aggressive fluid resuscitation. Too-rapid correction of hyperosmolarity may result in development of cerebral edema, especially in children. Subcutaneous heparin should be considered in patients with severe dehydration due to increased risk of thrombosis from hypovolemia and hyperviscosity.
Regarding the development of cerebral edema in patients being treated for DKA, all of the following are true EXCEPT:
A. Children have a higher incidence of cerebral edema.
B. Patients with serum glucose below 250 mg/dL still being treated with insulin are most likely to develop clinically evident cerebral edema.
C. Mortality of patients developing cerebral edema is 90%.
D. Mannitol and steroids should be administered immediately to any patient suspected of developing cerebral edema.
E. Cerebral edema typically occurs six to ten hours following onset of treatment.
The answer is D. Steroids are not indicated for treatment of cerebral edema and may actually worsen DKA. Mannitol 0.25-2.0 mg/kg should be administered upon any change in mental status of children being treated for DKA as they are at high risk for developing cerebral edema especially when being treated with insulin and serum glucose is below 250 mg/dL.
Of the choices below, the best treatment of the patient with hyperkalemia and EKG changes is:
The answer is C. Hyperkalemia with EKG changes is treated with calcium to stabilize cardiac membranes. Calcium works quickly and is relatively safe unless patients are digitalized. Other treatments for acute hyperkalemia include sodium bicarbonate and insulin/glucose.
Which pharmacologic treatment for hyperkalemia works through stabilization of cardiac membranes?
B. Insulin and glucose
The answer is A. "Immediate antagonism of K+ at the cardiac membrane is achieved with IV administration of calcium chloride or gluconate. This is indicated in patients with unstable dysrhythmia or hypotension."
A 55-year-old female with a history of end-stage renal disease presents to the emergency department with weakness. Her electrocardiogram is shown below. What is her most likely diagnosis?
A. Acute MI
The answer is D. The EKG shows signs of hyperkalemia as characterized by diffuse peaked T waves. Other EKG changes include widening of the QRS complex and biphasic QRS-T segments. The heart rate may be slow, with ventricular fibrillation and cardiac arrest as the terminal events. Acute myocardial ischemia can be represented by hyperacute T waves as well, but in these cases the T wave changes are more likely to be focal (i.e. in an anatomical distribution corresponding to the area of threatened myocardium).
Regarding the diagnosis and treatment of hypoglycemia, which of the following is correct?
A. Glucagon, administered intramuscularly or subcutaneously, is a safe and universally effective means for increasing blood sugar in hypoglycemic patients.
B. Hypoglycemia can present with virtually any neurological deficit.
C. Hypoglycemia in adults is typically symptomatic at or below serum glucose of 60 mg/dL.
D. Patients who overdose on oral hypoglycemic agents such as sulfonylureas must have their serum glucose monitored for a minimum of 6 hours before emergency department discharge.
E. Patients with type 1 diabetes do not typically develop hypoglycemia.
The answer is B. Glucagon is ineffective in patients without adequate glycogen stores, as would be expected in alcoholics. Further, glucagon can precipitate a severe lactic acidosis in patients with glycogen storage diseases and therefore should not be used in children with hypoglycemia of unknown etiology. Typical symptoms of hypoglycemia include sweating, tachycardia, nervousness, hunger, and neurologic symptoms. Symptoms should not be attributed to hypoglycemia unless the level falls below 40-50 mg/dL. Type 1 diabetics practicing strict control of serum glucose are at high risk for hypoglycemic episodes precipitated by skipping a meal, or by increasing energy output or insulin dose. Due to the extended half-lives of the oral hypoglycemic agents, hospitalization and 24-hour observation (at minimum) are the typical management for overdose of these agents.
A 20 year old man was ice skating on a frozen pond and fell through the ice. The water was only about six feet deep and he was able to keep his head above water while bystanders were able to extract him after 10 minutes. The patient was transported to the emergency department and had an initial core temperature of 30 C. The patient's wet clothes were immediately removed and rewarming was initiated. Which of the following physical examination findings is expected?
C. Altered mental status
The answer is C. Moderate hypothermia is associated with temperatures of 28-32 C. Shivering ceases at about 32 degrees Celsius. Moderate hypothermia is associated with altered mental status, absence of shivering, bradycardia, and bradypnea.
A 36 year old male backpacking in the wilderness loses his way in a snowstorm. Temperatures are well below zero degrees and his clothing is inadequate. He is rescued 5 days later and presents to the ED. Rescue crew has already initiated passive rewarming and have removed patient's damp clothing. On arrival, vital signs show pulse of 100 and temperature of 35.5C. On physical exam, you note patient has several toes that are purple with hemorrhagic blisters on his feet. Which of the following is the most appropriate initial management?
A. Immersion in warm water bath
B. Debridement of necrotic tissue
C. Tetanus prophylaxis
D. Administration of morphine
The answer is A. Immersion of the affected extremity is the mainstay of treatment for patients with frostbite. Numbness of the affected area is the most common initial symptom and severe pain is frequently encountered after rewarming. Tetanus prophylaxis and debridement is indicated , but is not the most appropriate initial step in the management of patients with frostbite. CDEM Hypothermia.
All of the following are true regarding the epidemiology of hypothyroidism EXCEPT:
A. Approximately half of myxedema cases are diagnosed after admission to the hospital.
B. Hypothyroidism occurs three to ten times more frequently in women than men.
C. Hypothyroidism does not occur in infants under six months of age.
D. Peak incidence of hypothyroidism is in the seventh decade.
E. Most cases of hypothyroidism manifest in the winter months.
The answer is C. Hypothyroidism may occur at any age including the very young, but is infrequently seen in infants due to regular newborn screening for hypothyroidism. The increased frequency of the disease in women is attributed to the increased prevalence of autoimmune thyroid conditions in women. The majority of cases present in winter months due to the body's decreased ability to accommodate to cold weather in a hypothyroid state.
With regard to laboratory findings in hypothyroidism, which of the following is false?
A. Free thyroxine (T4) is always depressed in hypothyroid states.
B. T3 level may be normal in hypothyroid states.
C. Total thyroxine levels may be normal due to elevated thyroxine-binding globulin (TBG) levels.
D. Free T4 and TSH levels are typically low in secondary and tertiary hypothyroidism.
E. Serum thyroid-stimulating hormone (TSH) is the most sensitive test to diagnose primary hypothyroidism.
The answer is A. Free T4 may be normal in early stages of hypothyroidism due to physiologic compensation from elevated TSH levels.
Metabolic abnormalities often seen with hypothyroidism include all of thefollowing EXCEPT:
C. respiratory acidosis from hypoventilation
The answer is E. Hyperglycemia is not typically associated with hypothyroidism. Hypoglycemia may be present, but is unusual, and may suggest hypothalamic-pituitary involvement. Hyponatremia is common and corrects with thyroid replacement. Hypercholesterolemia to over 250 mg/dL is typical. A mild normochromic, normocytic anemia may be present, in addition to respiratory acidosis from hypoventilation.
Laboratory abnormalities typically seen with adrenal insufficiency include all of the following EXCEPT:
The answer is A. Hyperkalemia is seen in approximately 64% of patients with adrenal failure. Typically this is because of aldosterone production failure that normally enhances potassium excretion. Even more common is hyponatremia, present in 88% of patients. Hypoglycemia is present in two-thirds of patients and is a significant cause of morbidity and mortality associated with adrenal failure. Hypercalcemia is seen in 6 to 33% for unclear reasons; azotemia and increased hematocrit from hypovolemia may also be present.
Regarding the treatment of suspected but not confirmed adrenal insufficiency, which of the following is most appropriate?
A. withholding of steroids until confirmation of the diagnosis of adrenal insufficiency
B. cosyntropin 0.25mg IV x 1
C. cortisone 100mg IM every 6 hours
D. hydrocortisone 100mg IV every 6 hours
E. dexamthasone 4mg IV every 6 hours
The answer is E. Dexamthasone is the treatment of choice in suspected but not confirmed adrenal insufficiency. It will not affect the serum cortisol level; therefore, it will not interfere with the diagnosis of adrenal insufficiency using the ACTH stimulation test. Administering cosyntropin, a synthetic form of ACTH, and measuring the serum cortisol levels typically perform the ACTH stimulation test. In confirmed adrenal insufficiency, hydrocortisone IV or cortisone IM are the treatments of choice.
Symptoms of secondary adrenal insufficiency include all of the following EXCEPT:
C. nausea and vomiting
D. weight loss
The answer is B. Hyperpigmentation is seen in greater than 90% of primary adrenal insufficiency. It is a result of compensatory adrenocorticotropic hormone (ACTH) and melanocyte-stimulating hormone (MSH) secretion. The secretion is a feedback mechanism that is not activated in secondary adrenal insufficiency, for example, adrenal insufficiency from pituitary infarction or hypothalamic insufficiency.
Treatment with hyperbaric oxygen (HBO) is associated with contraindications. Which of the following is not a relative or absolute contraindication to HBO?
B. untreated pneumothorax
C. COPD with air trapping
D. otitis media
The answer is A. Untreated pneumothorax is an absolute contraindication to HBO therapy. The reason is concern that it can progress to tension pneumothorax, especially during the decompression phase of therapy. The COPD patient with a large bleb represents a relative contraindication for similar reasons. Treatment with doxorubicin, and many other drugs -- such as cisplatin (Cisplatinum®), bleomycin (Blenoxane®), disulfiram (Antabuse®), and mafenide acetate (Sulfamylon®) -- contraindicates HBO therapy because of potentially toxic effects when combined with HBO. URI illnesses such as otitis media are relative contraindications, due to the potential for tympanic membrane rupture secondary to inability of the ears to equalize pressure during therapy. This can be addressed through myringotomy with placement of tubes (in cases where multiple HBO treatments are anticipated). In pregnant patients, HBO therapy has been shown to be safe for the fetus when given at appropriate levels and "doses" (durations). In fact, pregnancy lowers the threshold for HBO treatment of carbon monoxide-exposed pregnant patients. This is due to the high affinity of fetal hemoglobin for CO.
Which of the following is NOT a potential indication for hyperbaric oxygen therapy?
A. carbon monoxide poisoning
B. decompression sickness
C. necrotizing enterocolitis
D. necrotizing fasciitis
The answer is C. According to the Undersea and Hyperbaric Medical Society, items A-D are all reasonable indications for the use of hyperbaric oxygen therapy. Other potential indications include patients with air or gas embolism, crush injury, and compartment syndrome.
A 23 year old college novice mountain climber decides to climb a mountain with friends as a graduation present. His first night is spent at an altitude of 8,500 feet at a mountain resort. The next morning he starts to experience a mild headache and nausea. His symptoms get worse throughout the day. His friends want to get to 10,000 feet by nightfall. As a physician at the hotel, the worst advice you can give him is:
A. Take supplemental oxygen.
B. Ascend with the rest of the team.
C. Take acetazolamide.
D. Take ibuprofen.
The answer is B. The syndrome of high altitude illness ranges from mild AMS (Acute Mountain Sickness) to life threatening conditions of HAPE (High Altitude Pulmonary Edema) and HACE (High Altitude Cerebral Edema). This student is experiencing mild AMS. After the symptoms of altitude illness occur, further ascent to a higher sleeping altitude is contraindicated. Halting ascent or activity to allow further acclimatization may reverse symptoms. Acetazolamide is a carbonic anhhydrase inhibitor that induces a renal bicarbonate diuresis, causing a metabolic acidosis and thereby increasing ventilation and arterial oxygenation. Supplemental oxygen addresses the hypoxic insult of high altitude exposure. Ibuprofen is useful for the treatment of his headache. Dexamethasone can help with the symptoms of AMS, but does not play a role in acclimatization.
A 65-year-old female presents with a chief complaint of palpitations and dyspnea on exertion. Vital signs are BP 130/84, HR 160 (and irregularly irregular), RR 14, T 37.8. EKG shows a narrow complex, irregularly irregular rhythm with absence of p-waves and an undulating baseline. What endocrine abnormality is most likely to be a direct cause of this abnormal rhythm?
B. Addison's disease
C. Cushing's syndrome
The answer is D. Atrial fibrillation is a common arrhythmia. Its hallmark is the absence of P waves and irregular rhythm. It is associated with many medical conditions including ischemic heart disease and thyrotoxicosis. Atrial fibrillation increases the risk of thrombus formation and arterial embolism. AF's many treatment options include calcium channel blockers, beta blockers, amiodarone, quinidine, and cardioversion. Pacing is not a treatment option.
Regarding the diagnosis and treatment of thyroid storm in the emergency department, which of the following is true?
A. A stat thyroid-stimulating hormone (TSH) level is required to make the diagnosis.
B. Patients suspected of having thyroid storm should undergo treatment prior to a definitive diagnosis due to the potentially life-threatening nature of this disease.
C. The diagnosis of thyroid storm is generally a straightforward clinical diagnosis and rarely confused clinically with other disorders such as psychiatric or other endocrine disorders.
D. Thyroid storm cannot be diagnosed in the absence of altered mental status.
E. Treatment of thyroid storm should only be undertaken after consultation with an endocrinologist.
The answer is B. The diagnosis of thyroid storm in the emergency department may be challenging due to the relatively infrequent occurrence of the disease and its typically nonspecific signs and symptoms. Treatment should be initiated in a timely fashion in any patient suspected of having thyroid storm due to the potential lethality of this disease. Immediate laboratory testing is typically not available to confirm clinically suspected cases, although thyroxine (T4) radioimmunoassay and free T4 index are good screening tests for hyperthyroidism. Clinical presentation of thyroid storm may be mistaken for psychiatric illness, heat stroke, sympathomimetic toxidromes, hypoglycemia and withdrawal syndromes, among others. Altered mental status, though frequently present, is not a prerequisite for diagnosis.
Which of the following is not a common sign or symptom of thyrotoxicosis?
A. congestive heart failure
The answer is B. Fever, not hypothermia, is commonly seen in thyrotoxicosis. Other common signs and symptoms include tachycardia, congestive heart failure, wide pulse pressure, tremor, thyrotoxic stare, thyromegaly, nervousness, weight loss, and palpitations.
Which of the following is true regarding the use of iodine in the treatment of thyroid storm?
A. Iodine should be administered even in patients with known iodine allergy.
B. Iodine should be the first drug administered in the treatment of thyroid storm.
C. Iodine should be administered at least one hour after propylthiouracil (PTU) has been given.
D. Iodine should be administered only after treatment with propranolol.
E. Dexamethasone must be given 30 minutes prior to iodine administration.
The answer is C. Iodine inhibits preformed thyroid hormone release and should be administered at least one hour after treatment with PTU to prevent organification of iodine. A typical dose is potassium iodide (SSKI) 5 drops every 6 hours PO or NG, or sodium iodide 1 gm slow IV drip every 8 to 12 hours. Iodine should not be administered to patients with known iodine allergy.
All of the following are commonly used in the supportive treatment of thyroid storm EXCEPT:
A. acetaminophen to manage hyperpyrexia
B. amiodarone to control dysrhythmias
E. diuretics to treat congestive heart failure
The answer is B. Amiodarone is an iodine-rich antidysrhythmic with poorly-defined effects on thyroid function that has been associated with both hyperthyroidism and hypothyroidism. It should therefore be avoided in the management of thyroid disease. Propranolol is standard therapy in thyroid storm and, in addition to its effects of adrenergic blockade, also may reduce dysrhythmias. Of note, aspirin should be avoided in the treatment of hyperpyrexia as it may increase the level of active thyroid hormone by displacing thyroid hormone from thyroglobulin.
A 4 year old girl is brought to the ED two hours after being stung by a scorpion while on a camping trip in Arizona. She has periods of agitation and restlessness alternating with calmness. Her vital signs are: blood pressure 106/61, pulse 120, respiratory rate 24, temperature 37.0C, and oxygen saturations of 99% on room air. On physical examination you note drooling, a disconjugate gaze, and occasional jerking movements of the extremities. Which of the following is the most correct regarding the treatment of a scorpion sting in this child?
A. Treatment with antivemon is not indicated because these symptoms will be self-limiting
B. Analgesics have a minimal role in controlling symptoms
C. The patient should be intubated because respiratory failure is expected
D. Complications of treatment with antivenom include delayed serum sickness
The answer is D. Most scorpion envenomations are mild, limited to pain and paresthesias at the site of envenomation. Children are affected more severely than adults: restlessness, jerking movements of the limbs, roving eye movements, and drooling are seen in severe cases. Anaphylaxis can also occur. Intubation is required rarely. Most envenomations require analgesics only; antivenom is indicated for severe reactions and anaphylaxis. Antivenom treatment is not without complications - serum sickness, and immediate and delayed hypersensitivity reactions occur. Without antivenom treatment, symptoms usually last for 1-2 days.
A 24 year old female gardener presents to the emergency department with foot pain 30 minutes after working barefoot in her garden. She saw a scorpion in the area. Which of the following signs or symptoms are most expected?
A. Cranial nerve abnormalities
B. Puncture mark
C. Local erythema and swelling
D. Pain and paresthesias
The answer is D. Although there are many toxic species of scorpions in the world, and all can sting humans, only a few cause serious toxicity. In the United States, only Centruroides exilicauda is capable of causing systemic toxicity. The sting is followed immediately by localized pain and paresthesias, and these can progress to involve the entire extremity or body. Systemic symptoms are unusual in adults, but more common and severe in children. Evidence of a sting, such as a puncture wound is almost never seen on exam. The mainstay of treatment is analgesia. Although antivenom is very effective in alleviating symptoms, both immediate and delayed allergic reactions occur with its use. Routine use of antivenom is not indicated, as most symptoms usually resolve in 1-2 days
A 5 year old male is bitten by a snake while playing along a ditch. The child is brought to the ED by his parents with complaint of fang marks to the right index finger. On physical exam, you note absence of swelling to the right hand or fingers. He does appear to have 2 small superficial fang marks, but no bleeding or oozing is present. Vital signs are normal. What is the next most appropriate step in the management of this patient?
A. Admit for observation of potential compartment syndrome
B. Administer prophylactic antibiotics with gram positive sensitivity
C. Administer weight based antivenom in pediatric patients
D. Discharge home in 8 hours if patient's exam remains unchanged
The answer is D. The patient is unlikely to suffer envenomation if he does not have any local or systemic symptoms in 8 hours. The dosage of antivenom is dependent on the degree of symptoms and children receive a proportionately higher dose compared to adults. Prophylactic antibiotics are not recommended
An 80 year old female presents to the ED with mental status changes after her neighbors found her this morning wandering in the stairwell. Patient was last seen normal 4 days ago and has no medical problems. On arrival to the ED, she is agitated and confused. Vital signs include RR of 20, HR of 100, BP of 90/50, and temperature of 40.6 Celsius. Pt is oriented to person only and is inattentive to exam, but appears to move all extremities symmetrically. She does not follow commands. Mucous membranes are dry and skin is dry and hot. What is the most likely diagnosis?
A. Serotonin syndrome
C. Thyroid storm
D. Heat stroke
The answer is D. Heat stroke is a life-threatening illness defined clinically as a core body temperature that rises above 40.5 degrees Celsius and is usually accompanied by hot, dry skin (though in some cases sweating may be present) and central nervous system abnormalities such as delirium, convulsions, and coma. Treatment goals include lowering the core temperature to < 39.4 degrees Celsius by promoting cooling through conduction and evaporation and treating the complications that might arise with heat stroke, including seizures, respiratory failure, hypotension, rhabdomyolysis, and multi-organ dysfunction syndrome. Acute anticholinergic toxicity may sometimes present with a picture like that of heat stroke, and although the answer options C, D, and E may lead to confused behavior and/or fever in an elderly individual, the constellation of symptoms seen in this woman is most suggestive of heat stroke.
A 55 year old male, who has been missing for several days in wintertime, is found in a forested area several miles away from his house. He is brought to the ED where he is found to have a core temperature of 27 degrees Celcius. He clearly has diminished mental capacity. His initial ECG demonstrates atrial fibrillation with a ventricular rate of 110. Which of the following is the best treatment option?
A. Start calcium channel blockage
B. Apply a Bair Hugger
C. Administer warm IV fluids
D. Immerse in a warm water bath at 40 Celcius
The answer is C. The patient is suffering from severe hypothermia. Atrial dysrhythmias are common below 32o C and are associated with a slow ventricular response. It usually converts spontaneously with rewarming. While answers B through E are all active rewarming techniques (active external - Bair Hugger, AVA rewarming, immersion, active core - peritoneal lavage), the best answer for someone with severe hypothermia with mental status change and cardiac dysrhythmias is probably active core rewarming . This technique minimizes rewarming collapse in patients with temperatures below 32o C. The patient will likely need intubated as ileus, bronchorrhea, and depressed protective airway reflexes are common with hypothermia.
A 48 year old farmer is plowing his field when a thunderstorm rapidly overcomes him. Drivers on a nearby highway see him struck by lightening. You respond to the scene with EMS. What is the least likely finding on physical exam?
A. cardiac asystole
B. Glascow Coma Score of 3
C. extensive skin burns
D. respiratory arrest
The answer is C. A lightning strike is the discharge of a massive amount of current over a very short period of time. This often causes "short-circuiting" of electrical systems such as heart, respiratory centers, and central and autonomic nervous systems, in addition to arterial and muscular spasm. However, significant skin burns and deep tissue destruction seldom occur.
THIS SET IS OFTEN IN FOLDERS WITH...
SAEM - Chest Pain
SAEM - Pulm Emergencies
Altered Mental Status
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