NMS Q&A Family Medicine

6 NMS Q&A Family Medicinebe defined as treatment taking place when there is backpain only (Stage 1) or pain with radiculopathy (Stage 2).If motor weakness (Stage 3) or paralysis sets on, interventionshould take place within 24 to 36 hours; the longerthe delay beyond 24 hours, the worse the ultimate result.8. The answer is A . CT scan of the head without contrast.An acute event in the head as described is quite likely to behemorrhagic; the “worst headache I’ve ever had” is a subarachnoidhemorrhage until proven otherwise. Contrastis not needed to see hemorrhage of or around the brain.9. The answer is C . Instruct her husband in checking thepatient’s pupil sizes and reactivity plus her state of alertnessfrequently over the next 48 hours.10. The answer is B . CT scan of the head without contrast.The chief concern at this time would be to rule out atemporal-bone skull fracture transecting the middle meningealartery, resulting in epidural hemorrhage. This is anarterial hemorrhage, and the classic clinical presentationis head trauma with or without attendant concussion followedby a “lucid interval” of minutes to 24 to 48 hours,after which the patient becomes obtunded (decreasinglevel of consciousness). It constitutes a neurosurgicalemergency. CT need not—and should not—be carriedout with contrast since the presence of blood is clearlyshown without contrast. CT is superior to MRI in showinghemorrhage within or on the brain. Reexamination isunlikely to produce a reassuring result and would costvaluable time. Calling the neurosurgeon might be appropriateafter the order for the CT scan, but the latter wouldtake precedence in urgency since it would have to beaccomplished in any event.11. The answer is C . Magnesium sulfate is the tocolyticmedication most likely to be associated with respiratorydepression. Nifedipine and indomethacin, while used astocolytics, do not cause respiratory depression. Terbutalineand ritodrine cause respiratory distress due to pulmonaryedema but do not suppress respiration.12. The answer is B . Irregular testicular mass. Testiculartorsion is a surgical emergency requiring correctionwithin 6 hours to avoid the loss of spermatogenesis.Testicular torsion occurs in adolescent boys older than12 years. The cremasteric reflex is virtually absent. 99mTcor color Doppler ultrasonography is 95% “accurate”(implying 95% sensitivity and 95% specificity). However,specificity is clinically 95%, because damage may ensuewith 360 degrees of torsion, thus allowing some arterialcirculation. Emergency surgery should not be withheld ifthe clinical picture is otherwise compatible with the diagnosis.Although the testicle is classically found to ridehigher than the contralateral organ, it retains its naturalshape. An irregular mass is most likely caused byepididymitis or, if present over time and painless, possiblycancer.13. The answer is C . Patients who are on SSRIs along withserotonin-increasing drugs such as tramadol, meperidine,monoamine oxidase inhibitors (MAOIs), sibutramine,sumatriptan, lithium, St John’s wort and Ginkgo mayresult in serotonin syndrome. Findings include mentalstatus changes, agitation, myoclonus, hyperreflexia, diaphoresis,goose bumps and shivering, tremor, diarrhea,ataxia, and fever. This can be life threatening. Further,SSRIs can increase the levels or pharmacological effects ofwarfarin and of the tricyclic antidepressants. Although theother choices are each somewhat plausible in certaindetails, the drug interaction described is by far the mostlikely under the circumstances portrayed in the vignette.14. The answer is D . BNP secreted in the ventricles is asensitive indicator of CHF and may be helpful in differentiatingcardiac dyspnea from other causes of dyspnea such asCOPD, reactive airway disease and air hunger from acuteblood loss. Although there is a gray zone of uncertainty inevaluating the significance of BNP, a level 100 pg/mLexcludes CHF and a level 400 pg/mL confers a 95%chance of CHF.15. The answer is D . Septal hematoma. This must bediagnosed and drained as soon as possible to avoid infectionand a saddle nose deformity. The reduction of thefracture can wait to be dealt with electively over the followingfew days. Of course, the other diagnoses mentionedshould be ruled out since they may have occurredconcomitantly. Basal skull fractures classically manifestraccoon eyes and spinal fluid rhinorrhea; orbital andzygoma fractures manifest palpable deformity and appropriatetenderness to palpation; simple, uncomplicatedfractures of the nose, while they may bleed, do not manifestsubmucosal hematoma in the nose.16. The answer is B . Apply a thumb spica and wrap inACE bandages for 2 weeks, at which time the x-rays arerepeated. This is to rule out a fracture of the scaphoid(navicular, semilunar), showing only by an emerging fractureline, which may have been missed in the acute films.The scaphoid has arterial supply only from the distal end ofthe bone. Thus, if the fracture is not carefully immobilizedfor an adequate period of time, the result is aseptic necrosisof the proximal end and chronic pain in the wrist.17. The answer is B . Wernicke’s encephalopathy. Alcoholwithdrawal leading to delirium tremens, in the absence ofadequate nutrition, occurs with a drop in blood alcohollevel from the range at which it has been for significantperiods of time, even when there may be significant levels