2019. QUIZ 17. WEEK 02

Question 1

Your patient is a 65 year old male presenting with a complaint of syncope. In a thorough history the patient states he did not ‘’go down completely’’. You feel reassured because it appears the patient had near-syncope instead of syncope, but should you?

A: Yes, near syncope is always benign

B: Yes, near syncope is not harmless but more often benign than syncope

C: No, near syncope = syncope when it comes to prognosis

The correct answer is C

Apparently near syncope is not is benign as it is often believed to be. This recent paper found for similar number for near syncope and syncope regarding the composite outcome of 30-day death or serious clinical event. However, all patients in this paper where 60 years or older and these results cannot be applied to a younger patient group.

REBEL EM posted about the article earlier this week.

And have a look at the paper in Pubmed here.

Question 2

What would be considered typical for a Q wave in Hypertrophic CardioMyopathy (HCM)?

A: The Q waves are wide (>40 ms)

B: The Q waves are found anteriorly (V2-V3-V4)

C: The Q waves are shallow

D: The Q waves are narrow (<35 ms)

The correct answer is D

Q-waves in HCM are typically deep, narrow and clean (dagger-like) and are found in the lateral and of inferior leads.

emDOCS published this post about HCM.

Question 3

You treat a patient with shingles and you give advice about wound care and contact precautions. Furthermore you consider prescribing antivirals and steroids. Which statement is correct regarding these treatments?

A: Both Antivirals and steroids have no effect on pain the the acute phase (1 month from diagnosis), but will prevent post herpetic neuralgia

B: Antivirals will reduce pain in the acute phase (1 month after diagnosis) and steroids might reduce pain in the acute phase but both do not affect post herpetic neuralgia

C: Steroids reduce post herpetic neuralgia and antivirals reduce pain in the acute phase

D: Antivirals reduce post herpetic neuralgia and steroids reduce pain in the acute phase

The correct answer is C.

First of all, there is no evidence that steroids or antiviral drugs reduce the incidence and severity of post herpetic neuralgia. However, there is some evidence that antivirals reduce pain in the acute phase. Steroids might do this as well, but evidence is even more limited.

Well, no definite answer here, but it seems both therapies are worth considering in your patient with shingles.

SinaiEM discusses 2 recently published Cochrane review about this topic.

Question 4

What is NOT true about interpreting a proper thoracolumbar spine x-ray?

A: The tracheal bifurcation is at the level of T4 or T5

B: You will find the clavicle at the level of T3

C: Vertebral bodies and disc spaces decrease in size as you get further caudal

D: An increased distance between spinous processes should make you wary for a Chance fracture

The correct answer is C.

The vertebral bodies and disc spaces increase in size as you go further down the spine. A Chance fracture (hyperflexion of the upper lumbar spine due to incorrect use of a seatbelt) is an unstable fracture with ligamentous injury. We always struggle with the differences between Chance, Burst and Compression fractures, but Don’t forget the Bubbles helps us out with their recent post.

Thoracolumbar spine x-rays

Question 5

A 30 year old woman presents to your ED with shortness of breath and wheezing since 1 day. She has a history of asthma and tells you she visited a friend who owns a dog yesterday.

Which statement is correct about asthma triggers?

A: Trigger identification is only important for long term management

B: Paracetamol can exacerbate asthma

C: There is no such thing as a psychological trigger

D: Gastroesophageal reflux disease can exacerbate asthma

The correct answer is D

Trigger elimination is important in long and short term management. When a trigger like an infection is treated, it will shorten the duration of the acute illness and has effect on both morbidity and mortality. NSAIDs are a less known trigger for asthma ( paracetamol is not), and patients can be sensitive to these drugs. Psychological triggers can definitely exacerbate asthma, although there is not a lot of systematic and controlled research on this topic.

View the recently published post from emDOCS here.

Thanks for joining us again!

Eefje and Rick, the FOAMed Quiz Crew