Quiz 180, February 17th, 2023

Welcome to the 180th FOAMed Quiz.


Question 1

Source image: emedicine.medscape.com

A patient presents with anisocoria to your ED. She has a “down and out” appearance of the eye, ptosis and mydriasis of her right eye. When turning the light off, her right pupil fails to constrict. There are no other neurological abnormalities found in physical examination.

What is the most likely cause of this patient’s anisocoria?

A: Cranial nerve III palsy

B: Horner syndrome

C: Adie pupil

D: Anticholinergic drugs

The correct answer is A.

Anisocoria was discussed by EMdocs this week.

Horner syndrome is caused by compression of the oculomotor sympathetic pathway somewhere along its course. It causes ptosis and miosis instead of mydriasis and it will not cause extraocular movement disorders.

An Adie pupil arises from the parasympathetic denervation of the constrictor muscle, causing mydriasis, but no ptosis or extraocular movement disorders.

An anticholinergic toxidrome will cause bilateral mydriasis.

Anisocoria in the ED: Pathophysiology, Evaluation, and Management

Question 2

Source image: www.medicinenet.com

To what stage of syphilis belong nephrotic syndrome and isolated cranial nerve dysfunction?

A: First stage

B: Second stage

C: Third stage

The correct answer is B.

Syphilis was covered on DFTB last week.

The first stage includes a chancre also known as ulcus durum.

The second stage includes skin and mucosa lesions such as condylomata lata, hepatitis, nephrotic syndrome and cranial nerve damage.

The third stage includes neurosyphilis (tabes dorsalis, dementia paralytica) or heart problems, such as aneurysms or coronary arteritis.


Question 3

Source image: www.emdocs.com

Which of the following microorganisms is a known common trigger of Stephens-Johnson syndrome?

A: Legionella pneumoniae

B: Chlamydia pneumoniae

C: Mycoplasma pneumoniae

The correct answer is C.

Stephens-Johnson syndrome was covered in EMDocs last week.

A wide variation of Infections can cause Stephens-Johnson syndrome. Mycoplasma pneumoniae infections are the next most common infectious trigger.

EM@3AM: Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis

Question 4

Source image: www.litfl.com

De Winter T-waves are characterized by upsloping ST segment depression > 1mm at the J point in the precordial leads with tall T waves in the same leads and reciprocal ST segment elevation in aVR. It is a sign of occlusion myocardial infarction.

Which of the following coronary arteries is most likely occluded in case of de Winter’s T-waves?



C: Cx

The correct answer is B.

A case of de Winter T-wave was covered on Dr. Smith’s ECG blog last week.

The de Winter pattern is seen in about 2% of acute LAD occlusions.

Question 5

Thromboelastography (TEG) or rotational thromboelastometry (ROTEM) is a method of testing the efficiency of blood coagulation. It is used in emergency medicine with increasing frequency. The result of TEG is a reaction curve which shows the elasticity over time when the clot forms and dissolves.

The main parameters of the curve are:
R time: Time to initial clot formation
K time: Time from initial clot formation until reaching 20 mm in amplitude
Alpha angle (α): Angle between the baseline at initial clot formation
Maximum amplitude (MA): Maximum deviation of tracing to baseline
LY30: Amplitude 30 minutes after reaching maximum amplitude

The curve looks as follows:

Source image: www.tamingthesru.com

Whenever the R-time (time to initiation of cot formation) in a bleeding patient is prolonged, what should you do to promote clot formation?

A: Administer platelets

B: Administer cryoprecipitate (or fibrinogen)

C: Administer Fresh Frozen Plasma (FFP) or anticoagulation reversal agents

D: Administer tranexamic acid

The correct answer is C.

Taming the SRU covered TEG last week.

In case of a prolonged initiation of clot formation (R-time), we should administer FFP of reversal agents if the patient is on anticoagulation.

A prolonged K-time and a decreased alpha angle warrants cryoprecipitate administration.

A reduced maximum amplitude points you in the direction of platelet inactivity.

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This quiz was written by Sophie Nieuwendijk, Denise van Vossen, Nicole van Groningen, Jeroen van Brakel, Noortje Geerts and Renée Deckers

Reviewed and edited by Rick Thissen