Success is the sum of small efforts, repeated day in and day out.

• With primary hypothyroidism, you would expect a high TSH and a low T4. On physical, you may see periorbital edema, dry skin, and coarse brittle hair.  Patients often complain of weakness, fatigue, facial swelling, constipation, cold intolerance, and weight gain.
• With acanthosis nigricans, you would expect thickened, velvety, darkly pigmented plaques on the neck or axillae.  
• Cushing’s syndrome most commonly caused by hypercortisolism from an ACTH-secreting pituitary tumor. Cushing’s syndrome is diagnosed by a 24h urine cortisol and serum ACTH levels.

Now onto this week’s podcast.

Question 1

You are working in the ED when the police bring in a 26-year-old man who was involved in a bar fight. The patient is well known to staff as he frequently seeks treatment in the ED for injuries related to fights and alcohol abuse. He has been caught smoking cigarettes in the ED bathroom, has urinated on the floor, and been known to steal food trays and other patients’ belongings. As you enter his examination room, you overhear him giving the registration clerk a false identity. Which of the following personality disorders best fits with this patient’s behavior?

A. Antisocial

B. Borderline

C. Paranoid

D. Schizoid

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Question 2

A term pregnant patient presents to the ED in active labor and delivery. There is no meconium seen, but the baby has a weak cry and poor tone initially. After clearing the airway, drying the baby vigorously, and providing warmth, the poor tone persists. On exam, the heart rate is 85 and the newborn appears apneic. Which of the following is the most appropriate next step?

A. Administer atropine

B. Administer epinephrine

C. Begin chest compressions

D. Provide positive-pressure ventilations

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Question 3

A 13-year-old boy with no past medical history presents with a headache 3 days after a closed head injury. The patient states that he stood up from kneeling and hit the top of his head on a wood cabinet. There was no loss of consciousness or seizure activity. In addition to the headache, he complains of difficulty concentrating at school and dizziness. His physical examination is unremarkable. What management is indicated?

A. CT scan of the head with contrast

B. CT scan of the head without contrast

C. MRI of the brain

D. Neurology referral

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Question 4

Which of the following organs is the most commonly injured in adult blunt abdominal trauma?

A. Bladder

B. Intestine

C. Liver

D. Spleen

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Question 5

An 18-year-old man presents with red eyes. He has been sick with upper respiratory symptoms for two days. Examination is notable for bilateral conjunctival injection with scant discharge. He has rhinorrhea and sounds congested. He has a palpable preauricular lymph node on the left. Which of the following is the most likely cause of his red eyes?

A. Adenovirus

B. Rhinovirus

C. Staphylococcus aureus

D. Streptococcus pneumoniae

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Question 6

A 19-year-old man presents with pain in his index finger. Which of the following is suggestive of flexor tenosynovitis?

A. Delayed capillary refill

B. Holding the finger fully extended

C. Pain on passive extension

D. Swelling localized to the volar aspect of the finger

Teaching Image

• Those with antisocial personality disorder often display a blatant disregard for others, violate societal norms, and lack a remorse for their actions.  They are of often aggressive, irritable, and impulsive.
• Borderline personality disorder is a cluster B personality disorder and is characterized by self-destructive, impulsive behavior. They often have erratic emotions and may come off as being overly sexual and are frequently in crisis.
• Paranoid personality disorder is a cluster A personality disorder.  Paranoid patients are often cold, humorless, and suspicious.
• Schizoid personality disorder is also a cluster A personality disorder.  Schizoid patients are often loners with few friends who are indifferent to praise and criticism.
• In a neonatal resuscitation, the first step is to warm, dry, and stimulate the neonate and clear the airway if necessary.  If there is no response to these measures, begin positive pressure ventilation at a rate of 40–60 breaths per minute.
• Bradycardia in a newborn is often a sign of hypoxia.
• In a child over 2 with a GCS less than or equal to 14 or if are there signs of a basilar skull fracture or signs of AMS, there is a 4.3% chance of a clinically important traumatic brain injury. These children require head imaging.
• Postconcussive syndrome may present with many nonspecific symptoms, including headache, dizziness, confusion, amnesia, difficulty concentrating, and blurry vision without a focal neurologic finding.
• All patients with postconcussive syndrome should be referred to a neurologist for functional testing and tracking of symptom resolution.  Caution patients about returning to contact sports too soon to prevent a second impact.
• The most commonly injured organ in adult blunt abdominal trauma is the spleen. The liver is the second most commonly injured organ.
• Splenic lacerations are graded 1-5.  Most can be managed non-operatively.  Hemodynamic instability warrants an exploratory laparotomy.
• Conjunctivitis most commonly presents with redness, foreign body sensation, drainage, swelling of the lid, and even crusting in the morning. Treatment is supportive with compresses and artificial tears.
• The most common cause of conjunctivitis is a viral infection, with adenovirus being the most common virus.
• There are four cardinal signs of acute flexor tenosynovitis: 1) tenderness along the course of the flexor tendon 2) fusiform or symmetrical swelling of the finger 3) pain with passive range of motion 4) a flexed posture of the finger.
• Flexor tenosynovitis is most commonly caused by penetrating trauma and direct inoculation of the actual sheath, but direct spread from other areas of the hand occur as well.  
• Flexor tenosynovitis is a surgical emergency and requires antibiotics and hand surgery consultation.

So that wraps up Episode 29. From neonatal resuscitation to personality disorders with a brief stop in the trauma bay, we have covered quite a bit. Hope you all enjoyed. Don’t forget to email us or tweet us if you caught the time of the trauma ring tone to win the prize.

Until next time,
Jeff and Nachi

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