Quiz 48, November 1th, 2019

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Kirsten, Eefje, Hüsna, Joep and Rick


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Question 1

As emergency physicians we see a lot of septic patients coming into our emergency departments (ED’s). As early as possible administration of antibiotics sometimes conflicts with obtaining blood cultures before administration of these antibiotics. A recently published study, discussed in JournalFeed this week, compared positive blood cultures taken before and after administration of antibiotics.

What did this study find?

A: Administration of antibiotics before drawing blood cultures makes it harder to culture causative bacteria

B: The rate of positive blood cultures is the same as long as blood cultures are taken within 2 hours after administration of antibiotics in the ‘after’ group

C: It is reasonable to delay admission of antibiotics so blood cultures can be taken before the antibiotics will be administered, even if the patient is very ill

D: Timing does not matter at all, just make sure blood cultures are taken before the patient leaves the ED

​The correct answer is A

This recently published paper in Annals of Internal Medicine by Cheng et al. (september 2019) was discussed on JournalFeed this week and also reviewed by Rory Spiegel.

Cheng et al. included a total of 325 patients (aged 18 years and older) with severe sepsis (defined as having two SIRS criteria with a suspected or confirmed infectious source and either hypotension or a serum lactate > 4 mmol?L) from seven emergency departments. The data add proof to the long held belief that blood cultures should be taken before antibiotics are administered. However, sometimes antibiotics just need to be administered as soon as possible without any delay caused by taken blood cultures first.

EM Nerd-The Case of the Microscopic Imperative

Question 2

Last year 1182 people were diagnosed with measles in the United States. This was the highest number since 27 years. Emergency Physicians should be aware of this disease, especially in children with fever seen at the Emergency Department. Which of the following is true about Measles?

A: The ‘’classic’’ prodromes consist of: fever, conjunctivitis, and upper respiratory tract infection symptoms

B: Patients are only infectious in the first 48 hours after the onset of the maculopapular rash

C: The most common complication of measles is encephalomyelitis

D: If vaccinated, a child is 100% protected against the virus.

The correct answer is A

Last week ALiEM discussed measles.

The classic prodrome of symptoms consist of fever, conjunctivitis and upper respiratory tract symptoms. Children are infectious for 4 days before and 4 days after the onset of the rash. Measles are mostly if not always seen in children who are not vaccinated. Only 3% of vaccinated children get measles if regularly exposed. Only 1 in 1000 patients get encephalomyelitis. The complication of the measles leading to most deaths is pneumonia which occurs in 30% of hospitalized patients and is responsible for 60% of the deaths.

Measles 2019 Updates: The Comeback Kid

Question 3

Source: https://dontforgetthebubbles.com/

Last weeks post on Don’t Forget the Bubbles is about two kinds of palsy that can occur in the pediatric population; phrenic nerve palsy and Erb’s palsy. Which of the following statements is true ?

A: Phrenic nerve palsy’s most common cause is birth trauma

B: Erb’s palsy’s most common cause is birth trauma

C: Half of the patients with Erb’s palsy have associated phrenic nerve palsy

The correct answer is B

Phrenic nerve palsy causes hemidiaphragmatic paralysis, which compromises respiratory function. The most common cause is thoracic surgery, but can also occur with birth trauma. Mortality is reported up to 19 percent, and is even higher with delayed treatment. Treatment includes supportive respiratory care and most of the time surgical intervention. Erb’s palsy is a complex brachial plexus injury that causes paralysis of the arm. Most common cause is birth trauma, and most babies recover fully. There are similar risk factors for both palsies and in 2.4 percent of the patients with Erb’s palsy there is associated phrenic nerve palsy.

Question 4

Splenic abscesses are a rare condition, with an annual incidence rate of 0.05 – 0.7%. Despite this low incidence rate, it is important to have a high clinical suspicion of the condition in a subset of patients.

What is an important risk factor for the development of splenic abscesses, and which clinical findings can be expected?

A: Risk factor: endocarditis. Symptoms: generalized abdominal pain, diarrhea, leukopenia

B: Risk factor: deep skin infections. Symptoms: generalized abdominal pain, diarrhea, leukopenia

C: Risk factor: endocarditis. Symptoms: left upper quadrant pain, hiccups, leukocytosis

D: Risk factor: deep skin infections. Symptoms: left upper quadrant pain, hiccups, leukocytosis

The correct answer is C

EMdocs covered splenic abscesses last week. Early recognition of the condition is important for mortality rates are significant in missed or delayed diagnosis.

Splenic abscesses are quite frequently secondary to endocarditis. Risk factors include immunosuppression, prior splenic infarction, splenic trauma or hemoglobinopathies. Patients commonly present with fever, left upper quadrant pain and vomiting. In case of diaphragmatic irritation, patients usually have left shoulder pain and hiccups as well.

Splenic Abscess: ED Presentation, Evaluation, and Management

Question 5

Source: https://emsimcases.com

 Your 55 year old patient presents with diaphoresis, confusion and hypotension. During primary survey you notice a battery pack on his side and you realize he has a Left Ventricular Assist Device (LVAD). As the first sweat drops start to appear on your forehead, you try to remember everything you know about LVAD’s. Which of the following statements is true?

A: The LVAD patient will have a palpable pulse

B: The mean arterial pressure (MAP) should be measured with a doppler and a sphygmomanometer

C: On auscultation you shouldn’t be able to hear the device

D: The MAP goal for the majority of LVAD patients is between 40-60 mmHg

The correct answer is B

BrownEM covered LVAD issues this week.

The LVAD patient will most likely not have a palpable pulse, nor a measurable blood pressure. The mean arterial pressure (MAP) should be measured with a doppler and a sphygmomanometer. On auscultation, the physician should be able to hear the hum of the device. The MAP goal for the majority of LVAD patients is between 70-90mmHg.

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This quiz was written by Eefje Verschuuren, Kirsten van der Zwet, Hüsna Sahin and Joep Hermans

Reviewed and edited by Rick Thissen