Topics in Emergency Medicine

This specialty is also well represented on the examination and in
daily practice of emergency medicine-urgent care.



Q: What is a Felon?

A: It is a pyogenic infection of the distal pulp space of the finger. Usually due to
staphylococcal or streptococcal infections. Best therapy: Incision and Drainage
followed by 7-10 days oral antibiotics, against gram-positive organisms.




Q: What is a Fat Embolism Syndrome?

A: It occurs in patient with severe long bone injuries/fractures. The symptoms are due to
dislodged fat globules...causing an embolism, several days after the trauma.
Pts. usually exhibit hypoxia, restlessness, bilateral CXR infiltrates and kidney failure.
Treatment is supportive.




Q: What is Gas Gangrene (Myonecrosis)?

A: It is an infection caused by Clostridium perfringens. It causes rapid necrosis of fascia,
muscle and tendon. It usually occurs in traumatized or diabetic patients. Clinically, there
is palpable gas (crepitations) of the skin (also visible on X-rays) and intense pain.
Treatment: Aggressive IV antibiotics, surgical debridement and hyperbaric oxygen.




Q: What is Erysipelas?

A: It is cellulitis involving the facial structures (cheeks/nose) due to group A Strep Pyogenes.
The lesions is very painful, erythematous and edematous.
Treatment: Oral dicloxacillin. In PCN allergic patients, erythromycin.




Q: What is a External Hordeolum?

A: It's also called a Sty. An infection usually due to Staph. aureus, involving the eyelash
follicles. Treament: Usually self limited, after spontaneous drainage of the abscess.
Warm wet compresses 3-4 times daily for 15-20 mins. helps the healing process.
Bacitracin ointment can be supplemented.




We'll return soon....keep up the good work.

CLUES by ETHNICITY....

Many disoders occur within certain ethnic/racial groups.
This may seem obvious, but we often overlook this fact.
Many questions can be "guessed" based on just being aware.


The list is only partial and overlaps may occur...but on the exam, they
keep it simple and straightforward.



Disorders frequent to ASIANS:

1. Hepatitis E (HEV). It is the oriental equivalent of Hepatitis A. (HAV).

2. IgA Nephropathy (Berger's Disease) Occurs commonly in Asian males.

3. Kawasaki's Disease. Occurs mainly in oriental children.

4. Takayasu's Arteritis. A form of vasculitis mainly in younger women of East Asia.




Disorders frequent to MEDITERRANEANS: (Greeks/Italians/Armenians/Lebanese/Jews)

1. G6PD-Deficiency.

2. Familial Mediterranean Fever (FMF)

3. Beta Thallassemia

4. Tay-Sachs Disease. Occurs predominantly in Jewish populations.



Disorders frequent to CAUCASIANS:

1. Cystic Fibrosis. Especially Northern Europeans.

2. Heredirary Hemochromatosis

3. Wilson's Disease

4. Factor V-Leiden. Has a major Caucasion predominance.

5. Protein 20210 Mutation. Occurs mainly in White populations.

6. Alpha-1 Antitrypsin Deficiency



Disorders frequent to AFRICAN AMERICANS:

1. Sarcoidosis. A disorder of non-caseating granulomas.

2. Focal Segmental Glomerulosclerosis. (FSGS). African Americans have a high predisposition.

3. Sickle Cell Anemia (SSA)



Thanks thanks for your time....we'll continue next week.

Physical diagnosis....

We'll review the "classic" physical signs...that with great certainty, will be asked on the
board exam. Suggest, you memorize all of them.



Q: What is a Kussmaul Sign?


A: It is distention of the neck veins on inspiration. (This occurs in any condition that impedes
right ventricular filling, e.g. RV Infarction/CONSTRICTIVE PERICARDITIS/right heart
failure.


Q: What is Pulsus Alternans?


A: It is alteration in the amplitude (palpable force) of each pulse, due to left ventricular
contractive weakness. Each pulse is regular. Main conditions causing this are CARDIAC
TAMPONADE and severe LV decompensation.



Q: What is Tinel's Sign?


A: It is a common finding in patients with CARPAL TUNNEL SYNDROME. The sign
itself refers to "tapping" of the median nerve at the volar aspect of the wrist. This
causes, paresthesia (pins& needle senation). HINT: "T"apping---"T"inel's !!!!


Q: What is the Drop Arm Sign?


A: It is seen in patients with ROTATOR CUFF TEAR. The patient's arm is abducted
to 180 degrees. When asked to gently let down the arm....it will just suddenly drop
when reaching about 90 degrees....thus confirming the tear.



Q: What is an Iliopsoas Sign?


A: It is a physical finding suggestive of ACUTE APPENDICITIS. It is elicited by asking
the patient to raise the right leg against resistance. The pain...is
is caused by "rubbing" of the inflammed appendix against the inner peritoneal wall.



Q: What is a Cullen's Sign?


A: It is seen with conditions causing hemoperitoneum. Classically, it's associated with
NECROTIZING PANCREATITIS. The finding is a PERIUMBILICAL ecchymotic
like discoloration of the skin.


Q: What is Kehr's Sign?


A: Violent, severe pain in the left shoulder of a patient with RUPTURED SPLEEN.



Q: What is Chvostek's Sign?


A: It is an elicitation of unilateral facial irritability, by gently tapping over the facial
nerve, just anterior to the ear. It will cause facial grimacing, due spasm of the orbucularis
oris or oculi muscles. It is a sign of TETANY (HYPOCALCEMIA).





Keep up the good work!!! Study hard...reap the benefits later.....

Clinical gems...Pulmonary Medicine

We'll continue with interesting topics from the field of Pulmonology. Essentially,

illnesses caused by environmental/occupational factors.



Q: What is the most common cause of Mesothelioma?

A: ASBESTOS exposure-long term. (Of note, it is NOT associated with smoking).



Q: What is Farmer's Lung?

A: A pneumonia like illness, occuring 4-8 hrs. after exposure to MOLDY HAY.
The organism causing the illness is Thermophilic Actinomyces.



Q: What occupational illness causes "monday chest tightness"?

A: BYSSINOSIS...exposure to cotton dust. The release of histamine causes the tightness,
when the patient returns to the cotton processing work, after the weekend.



Q: Which occupational illness causes an markedly increased risk for Tuberculosis?

A: SILICOSIS...an illness due to quatrz exposure in foundry/glass workers.
The CXR actually shows a miliary(seed/millet) like finding, as in T.B.



Q: Which lung disease of coal miners is associated with Rheumatoid Arthritis?

A: CAPLAN'S Syndrome...a form of pneumoconiosis with a poor prognosis.



Thanks again, we'll be back next week. Feel free to post questions and comments.

Clinical gems....Hematology

We'll review some of the likely topics asked on the boards.



Q: What is the BEST diagnostic test for detecting iron deficiency anemia?

A: Serum Ferritin level... (serum iron test is mainly for screening)



Q: What physical SIGNS are highly specific for iron deficiency anemia?

A: Both.... Blue Sclera and Koilonychia...(spoon shaped fingernails)



Q: What infectious agent can cause sudden Aplastic Anemia in a young adult?

A: Parvovirus-B19 infection



Q: What disorder is the most common cause of vitamin B12 deficiency?

A: Pernicious Anemia... (due lack of gastric intrinsic factor)



Q: What peripheral smear finding is associated with Lead Poisoning?

A: Basophilic Stippling...(small granules in RBC's)



Q: What is the BEST test for definitive diagnosis of vitamin B12 deficiency?

A: Serum Methylmalonic Acid...( serum B12 level used mainly for screening).



Q: What is the MOST frequent blood transfusion reaction?

A: FNHTR (Febrile Non-Hemolytic Transfusion Reaction). Use Leukocyte reduced RBC's.



Q: Which type of anemia presents with paresthesias/ataxia/prominent NEURO symptoms?

A: Cyanocobalamin deficiency(B12). Causes demyelination of the dorsolateral portion
of the spinal cord. Foot burning...numbness are often the FIRST symptoms.


Q: Does deficiency of Folic Acid alone cause neurologic abnormalities?

A: No....only B12 deficiency.



More topics soon to follow...

Clinical gems.....Opthalmology

Clinical "gems" are especially helpful for the boards and in our daily practice.

So, let's review some of the important ones, likely to be presented to your on the exam.




Q: Wearing of contact lenses is a risk factor for which type of infection?

A: Pseudomonas...Keratitis (painful condition with photophobia w/o exudate)



Q: Finding of vesicles/dendritic ulcers on the conjunctiva, is associated with which infection?

A: HSV...Keratitis



Q: Finding of dryness and grittyness under the eyelids, is associated with which illness?

A: Sjogren's Syndrome



Q: Which conditions cause sudden PAINLESS visual loss?

A: Both CRAO (Central Retinal Artery Occlusion) & CRVO (Central Retinal Vein Occlusion).



Q: Which ocular condition is PAINFUL....Acute Closed or Open Angle Glaucoma?

A: Acute Closed Angle.....as the word "closed" implies. The pressure has no outlet.




Thanks again...we'll continue shortly.

EXAM TAKING WORD SKILLS.....

We'll return to the PSYCHOLOGY of exam taking. Some you may be familiar with, some may
not. So, it's useful to review a few tools you can use to your advantage. Especially, when you'll
just have to guess an answer.



Exam taking rule # 2. PAY ATTENTION TO THE WORDING !!!!

Whenever you see a sentence containing the following words: NEVER, ALWAYS,
RARELY, UNLIKELY....are most probably NOT the correct answers!!!!





Example: 1. A patients with Hodgkin's Lymphoma RARELY experience fever. (Quite the
opposite is true. One of the key features is, PAL-EBSTEIN FEVER).


Exaample 2. Travelers who receive immune prohylaxis prior to travel to the
Sub-Saharan Africa, NEVER develop malaria. (DRUG RESISTANCE is common
so, even with the best preventive measures, malaria can occur).


Example 3. Patient's with Adult Still's Disease ALWAYS experience a rash. (In fact,
they experience an EVANESCENT (come&go) faint salmon colored rash,
therefore making the diagnosis even more difficult).


Example 4. Patient's with Pseudotumor Cerebri are UNLIKELY to benefit from weight
loss. (Quite the contrary. These patients are usually obese young women, in
in whom, weight loss is often CURATIVE of their recurrent headaches).





Thanks for your time again....we'll continue soon and get into more detail on exam taking.