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Reach for it. Push yourself as far as you can.

-Christa McAuliffe

Welcome back to Roshcast Episode 35! It was great chatting with a bunch of listeners at ACEP last week. We received a lot of excellent feedback.

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This week, we’ll be doing a couple of diarrhea questions to link up with the last EM Clerkship episode, in addition to a few randomly generated questions. Don’t forget that we are still running a trauma ring tone contest. Listen closely for a ring tone in an upcoming episode and e-mail us at roshcast@roshreview.com or tweet to us at @Roshcast the exact time of the ring tone to win a prize, which will certainly come in handy as we get closer to the in-training exam. Let’s get started with a review from recent posts on the Rosh Review Blog.

• Pterygium is a fleshy triangular growth from the medial canthus towards the cornea. They are usually slow growing and seen in those with excessive sunlight exposure. They are managed with artificial tears.
• Pterygium typically doesn’t require surgery but may need excision if it is causing a visual disturbance. Make sure the patient is already following with an ophthalmologist or give them a referral if needed.
• Retinal detachments present with painless loss of vision, floaters, flashing lights, or as a curtain lowering sensation. On physical, you may see a hazy gray retina with whitish folds.
• The most common location for an ectopic pregnancy is the fallopian tube.

Now onto this week’s podcast

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Question 1

A 2-year-old girl presents after a witnessed seizure. The parents state that she has not been to daycare in two days, as she has bloody diarrhea and a fever. Her vitals on presentation are T 103.1°F, HR 167/min, BP 73/43 mm Hg, RR 48/min, and oxygen saturation 96%. Currently, the patient has a normal neurologic exam and minimal abdominal tenderness. There are no rashes. Labs show a WBC of 19,000, and urinalysis reveals an elevated specific gravity. Which of the following is the most appropriate next step in management?

A. Acetaminophen for fever and follow-up with primary care provider

B. Blood and stool cultures, IV antibiotics, and admission

C. Neurology consultation and admission

D. Oral antibiotics and follow-up with primary care provider

Teaching Image

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Question 2

An 82-year-old nursing-home resident is sent to the emergency department with lower abdominal pain and bloody diarrhea. He has a history of vascular dementia, hypertension, and hyperlipidemia. On examination he is afebrile, and a nasogastric aspirate is negative for evidence of bleeding. Which of the following is the most likely cause of this patient’s bleeding?

A. Angiodysplasia

B. Diverticular bleeding

C. Ischemic colitis

D. Peptic ulcer disease

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Question 3

Which of the following is considered a risk factor for suicide?

A. Female sex

B. First-trimester pregnancy

C. First year of marriage

D. Recent incarceration

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Question 4

Which of the following scenarios is most appropriate to safely discharge home a 2-year-old who has swallowed a coin?

A. The child is not drooling

B. The child is tolerating oral sips and the parents are reliable

C. The coin is in the stomach

D. The coin is oriented in the sagittal plane at the level of the clavicular heads

Teaching Image

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Question 5

A 35-year-old-man with a history of occasional bloody diarrhea and abdominal pain presents with acute onset severe abdominal pain. Vital signs are significant for a temperature of 39°C, heart rate 140/min, and blood pressure 82/55 mm Hg. On physical exam, his abdomen is distended and tympanic. Which of the following diagnostic studies is indicated first at this time?

A. Abdominal radiograph

B. Barium enema

C. CT scan of the abdomen pelvis with IV contrast

D. Sigmoidoscopy

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Question 6

A 45-year-old woman complains of two days of fluctuating diplopia and dysphagia. Her exam reveals a left cranial nerve VI palsy, ptosis, and proximal muscle weakness in her extremities. What is the pathophysiology of her disease?

A. Antibodies to the acetylcholine receptor at the neuromuscular junction

B. Inhibition of acetylcholine release at the synapse

C. Mutation of superoxide dismutase causing cell death

D. Reduced number of dopamine receptors in the midbrain

Teaching Image

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• Patients with Shigella often present with fever, abdominal cramps, and diarrhea with mucus or blood.  Infants with Shigella are also at risk for seizures.
• Shigellosis should be treated supportively.  Patients who are immunocompromised, have bacteremia, attend daycare, or live in a nursing home require treatment with antibiotics. Children should be treated with ceftriaxone, 50 mg/kg in a once-daily dose up to a max of 1.5g for 5 days.
• Ischemic colitis is caused by inadequate blood flow through the mesenteric vessels. It often affects the watershed regions.
• Ischemic colitis can be treated supportively with bowel rest and IV fluids unless there are signs of peritonitis or infarction.
• Risk factors for suicide include male sex, age, history of mental illness, personal or family history of a suicide attempt, poor financial situation, unemployment, poor physical health, being Caucasian, and isolation.
• With respect to suicide, marriage, and first-trimester pregnancy are both protective.
• Swallowed foreign bodies that do not pass through the esophagus, which occurs 2% of the time, have a risk for esophageal perforation or erosion.
• Emergent endoscopy is indicated if the swallowed foreign body is a battery, is sharp, or if there are signs of obstruction.
• Coins in the sagittal plane</s