Quiz 64, February 28th, 2020

Welcome to the 64th FOAMed Quiz. 


Eefje, Joep and Rick

Question 1

Source image: https://www.aliem.com/

Ankle injuries are common in the Emergency Department. Which of the following statements is true about ankle x-rays?

A: A tibiofibular space >2 mm indicates a syndesmotic injury

B: The AP view should be used to asses the medial clear space

C: A Bohler’s angle <20 degrees suggest a calcaneus fracture

D: A gravity stress view should be considered in Weber A fractures to assess for syndesmotic involvement

The correct answer is C

This week’s post on ALIEM is about the approach to the traumatic ankle x-ray. 

The tibiofibular space is widened in syndesmotic injury, when > 6 mm suspect a syndesmotic injury. 

The medial clear space is assessed on the mortise view. This is the medial border of talus and lateral border of medial malleolus. When > 4 mm there might be syndesmotic injury. 

Another approach to assess for syndesmotic injury is the gravity stress view. To be considered in Weber B fractures. 

Bohler’s angle is measured on the lateral view. If < 20 degrees, a calcaneus fracture might be present. You could then consider ordering a calcaneus view, although CT has higher sensitivity and specificity for this fracture.


Question 2

Source image: https://litfl.com/

You see a 70 year old patient with in the past medical history diabetes mellitus, hypertension and epilepsy. He presents with fever-like symptoms and an erythematous macular rash. There is mucosal and ocular involvement and the Nickolsky sign is positive. He has been taking penicillin recently.

Which of the following critical rashes do not have mucosal involvement?

A: Toxic Epidermal necrolysis (TEN )

B: Stevens-Johnson syndrome (SJS)

C: Staphylococcal scalded skin syndrome (SSSS)

D: Acute generalised exanthematous pustulosis (AGEP)

E: Pemphigus Vulgaris ( PV)

The correct answer is C

This week critical rashes were covered on emDocs.

Nickolsky sign is positive when lateral pressure on intact skin causes shedding of the epidermis. This sign can be seen in all of the above critical rashes. Mucosal involvement is common in TEN and SJS, and is less common, but can be seen in AGEP and PV. SSSS presents as erythematous painful skin with flaccid bullae and desquamation, but without mucosal involvement.

Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis Mimics – Differential Diagnosis and Initial Management

Question 3

Which combination of vasopressor and mechanisms of action is correct?

A: Vasopressin – increase in systemic vascular resistance and increase in pulmonary vascular resistance

B: Milrinone – positive effect on inotropy and decrease in pulmonary vascular resistance

C: Dopamine, low dose – decrease in systemic vascular resistance and increase in pulmonary vascular resistance

D: Phenylephrine – decrease in systemic vascular resistance and increase in pulmonary vascular resistance

The correct answer is B

This week’s chapter of the internet book of critical care on emcrit is about vasopressors. The table below gives a summary of the most commonly used vasopressors and their mechanisms of action.


Source image: https://emcrit.org/ibcc/pressors/
Source image: https://emergencymedicinecases.com

Question 4

Your 40 year old patient presents with acute chest pain. You find some ST-elevation (STE) in the precordial leads and you doubt whether you are looking at Benign Early Repolarization (BER) or an acute myocardial infarction (MI).

Which of the following findings may point you in the direction of MI?

A: Convex STE morphology

B: Concave STE morphology

C: Notching at the J point

D: Normal R wave progression

The correct answer is A

County EM covered Benign Early Repolarization Pattern vs. Anterior STEMI this week.

Convex STE morphology is highly specific for AMI, while STE at the J point with upward concavity is more typical for BER (but LAD occlusions can be seen with concave morphology).

Notching at the J point is typical for BER, as well as normal R wave progression (of course).

Benign Early Repolarization Pattern vs. Anterior STEMI

Question 5

Source image: https://first10em.com/

Your 34 year old patient presents with a linearly arranged itching rash over his trunk and arms 2 days after eating mushrooms. This presentation is typical for:

A: Type 1 (IgE mediated) hypersensitivity

B: Type 4 (T-cell mediated) hypersensitivity

C: Tinea corporis

D: Shiitake dermatitis

The correct answer is D First10EM covered shiitake dermatitis this week. ´Shiitake dermatitis is an intensely pruritic rash caused by a toxic reaction to lentinan, a component of shiitake mushrooms. It usually develops 1-3 days after eating raw or undercooked shiitake mushrooms.´ Type 1 hypersensitivity reactions occur earlier after exposure. Type 4 hypersensitivity can present 2 days after exposure, but as contact dermatitis. Tinea corporis has nothing to do with eating mushrooms.
Shiitake Dermatitis
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This quiz was written by Eefje Verschuuren and Joep Hermans

Reviewed and edited by Rick Thissen