By S. Gambal. Saint Anthony College of Nursing.

This is a condition where there is an abnormal development of the aorta buy 1mg prograf otc, the large vessel supplying blood to the body from the heart trusted 5mg prograf, which results in decreased blood fow to the lower body generic prograf 5 mg on-line. In our patient the symptoms have become more prominent in the sec- ond week of life as the ductus arteriosus closes effective prograf 5 mg. Labs generally are not helpful in the diagnosis of aortic coarc- tation, but can be used to rule out sepsis and to see if the patient is acidotic. Cyanosis, dyspnea, or diaphoresis during feeding can be a sign of a congenital heart defect. Prostaglandin E1 prevents closure of a patent ductus arteriosus, which can help stabilize an infant with a cyanotic heart defect. He notes eight to ten episodes per day, frst watery, now bloody, and associated with mild lower abdominal pain and cramping, fever, chills, and malaise. Patient denies nausea, vomiting, hematuria; denies recent travel or antibiotic use. Social: lives alone, denies alcohol, smoking, or drug use, not sexually active for 5 years g. Abdomen: hyperactive bowel sounds, nontender, no masses or organomegaly, no rebound or guarding l. Viruses most commonly cause gastroenteritis leading to diarrhea but in this patient because the diarrhea. However, the bloody diarrhea in this case is suggestive of an inva- sive bacterial etiology. History of travel, antibiotic use, known sick contacts, or ingestion of contaminated food during an outbreak are also suggestive of bacterial infection. Infectious diarrhea is usually self-limiting and does not require antimicrobial therapy except in severe cases, including bloody diarrhea or duration greater than 3 days. Culture should also be sent in children, toxic patients, immunocompromised patients, or patients with history of travel. Typical viruses causing diarrhea are rotavirus, adenovirus, calicivirus, astro- virus, and Norwalk virus. Viruses typically affect the small intestine and do not present with bloody diarrhea. Thrombotic-thrombocytopenic purpura and hemolytic-urenic syndrome is a complication of infectious diarrhea, usually caused by E coli 0157:H7, and should be considered in children presenting with grossly bloody stool and olig- uria or anuria. In a patient presenting with bloody diarrhea, other conditions that should be considered include diverticulitis, mesenteric ischemia, gastrointestinal hemor- rhage, and infammatory bowel disease. Patient cachectic, appears older than stated age, moderate respiratory distress, sitting up in stretcher. Patient denies headache, neck stiffness, abdominal pain, nausea, vomiting, diarrhea, upper respiratory, or urinary symptoms. Discussion with patient regarding goals of care and possibility of respiratory failure requiring endotracheal intubation M. The patient should also be placed in airborne isolation for possible concurrent tuberculosis. Patients meeting corticosteroid criteria or with otherwise tenuous respiratory status or predicted poor compliance should be hospitalized. Patient disheveled, appears older than stated age, mumbling incoherently, vom- itus around mouth. Circulation: warm skin, normal capillary refll Case 105: Altered Mental status 461 E. Lactate, alcohol level, acetaminophen level, salicylate level, urine toxicol- ogy screen d. Per friend accompanying patient, patient had been vomiting for the past hour, and then became confused with incoherent speech. Per friend, patient smokes one pack of cigarettes per day but does not drink alcohol, or use illicit drugs. Patient had been feeling increasingly depressed about living conditions over the past week but otherwise had no complaints. Neck: full range of motion, no jugular vein distension, no stridor 462 Case 105: Altered Mental status Figure 105. This presentation is a typical one, with nausea, vomiting, and mental status changes, and in the case of severe toxicity, progression to seizure, met- abolic acidosis and even. If a large dose of lorazepam is given, the patient should desaturate and need intubation. In acute overdose, typical presentation is with nausea, mental status changes, and ataxia, which may progress to seizure, coma, and metabolic acidosis if more than 20 to 40 mg/kg are ingested. Metabolic acidosis may occur in severe overdose with seizure activity, due to production of lactic acid. Patient appears cachectic, disheveled, with poor hygiene, and covered in urine and feces. Patient reports that his son is his caretaker but has not come by in several days. General: alert, oriented × 3, cachectic, disheveled, poor dentition and hygiene, covered in urine and feces b. Eyes: sunken eyes, extraocular movement intact, pupils equal, reactive to light d. Neck: full range of motion, no jugular vein distension, no stridor Case 106: weakness 467 Figure 106. Extremities: full range of motion, no deformity, normal pulses, ecchymosis around right arm o. The patient is in acute renal failure secondary to dehydration and has sacral decubitus ulcers from being left lying in bed unattended. Complete exposure and thorough physi- cal examination is key in exposing any signs of abuse or neglect. Ecchymoses encircling the upper extremities would be suggestive of the patient being grabbed or shaken; if found on the lower extremities, sexual abuse should be suspected. The candidate should look not only for signs of physical abuse, but sexual abuse and neglect as well. This patient is unsafe to return home and should be admitted for assessment of renal failure and social service assessment. The diagnosis of elder abuse rests on a clinician’s awareness of the problem, recognition of risk factors and red fags in a patient’s history, and a thorough physical examination. There are three basic categories of elder abuse: domestic abuse (occurring in the home), institutional abuse, and self-abuse or self-neglect. Elder abuse may present in the following forms (as defned by the National Center on Elder Abuse): i. Elder abuse should be reported by the clinician to the appropriate hospital staff and to the proper authorities as mandated by the state. Critical actions == Aspiration of joint to rule out septic arthritis == Pain management == Counseling on alcohol reduction O. Gout is an infam- matory reaction in the joint, most commonly the big toe, which is not infectious in origin and caused by uric acid crystal formation. This is a typical presenta- tion of gout, with acute pain evolving over hours, which may or may not be trig- gered by trauma, surgery, illness, or heavy protein load. In a patient presenting with pain and infammation of a joint, it is critical to rule out septic arthritis, infection of the joint. Patients with crystal-induced arthritis may present with low-grade fever and normal serum uric acid levels, further complicating the picture and making joint aspiration crucial. Disposition is contingent on exclu- sion of a septic joint and adequate analgesia. Patient should be counseled on alcohol cessation given it is likely worsening his gout. The majority of patients initially present with monoarticular disease, typically in the lower extremity. Acute attacks may be triggered by trauma, surgery, malnutrition, or overcon- sumption of meat, fsh, and/or alcohol. In both conditions, crystals are present; however, uric acid crystals in gout are needle-shaped and negatively birefringent, whereas the calcium pyrophos- phate crystals of pseudogout are rhomboid-shaped and positively birefringent. Serum uric acid levels are of low utility in the diagnosis of gout, as levels may be normal in many patients. Erythrocyte sedimentation rate is also low-yield in differentiating between crystal-induced arthropathy and septic arthritis, as levels may be elevated in both conditions. Patient appears stated age, uncomfortable appearing secondary to pain, holding head, in mild distress, lying still supine on stretcher.

It is important to avoid overlooking feathers and viewing the normal translucent avian less obvious injuries and unrelated problems prograf 1 mg mastercard. Greenish discoloration of the skin is normal in contaminants have been removed and before any bruised birds due to accumulation of biliverdin pig- antiseptics have been applied buy 1 mg prograf. This dis- has been shown to be ineffective for bacterial infec- coloration develops two to three days post-injury and tions order 5 mg prograf visa, but may be effective as a sporicide in cases of may persist for a week or more order 1 mg prograf. Other diagnostic tests used to assess an Wound debridement following lavage involves re- injured bird include microbiological cultures, hema- moval of as much of the devitalized and necrotic tology, radiology and ophthalmologic examination. Surface Preparation and Wound Treatment Topical medications in certain wounds may be bene- The initial goal in treating contaminants or infected ficial; however, use of non-water-soluble medications wounds is the removal of devitalized tissue, foreign should be avoided due to loss of insulation with soiled material and bacteria. Bacitracin, neomycin and polymyxin are effective against a wide spectrum of bacteria. Sterile isotonic sa- for pododermatitis in raptors and other birds is di- line with or without 0. After lavage and debridement, the wound should either be sutured, managed by second intention heal- ing or managed as an open wound with delayed closure. Fracture repair was un- eventful, but when the bandage was removed, a severe wing droop was still evident and muscle atrophy had occurred to the wing musculature. Advantages of thesef vide an optimal environment for epithelialization products for use in avian medicine include availabil- and wound contraction with the fewest complica- ity and low cost. This layer should be sterile, are impermeable to moisture vapor and oxygen, and remain in place even with patient movement, provide absorb fluid and exudate to develop a moist, gelati- a moist wound environment and assist with the de- 32 nous cover over the wound. Adherent dressings Hydrocolloid dressings have been used successfully in a variety of avian species,9,11,12,17 and are most such as fine mesh or open weave gauze pads are indicated during the initial phase of wound treat- useful for extensive wounds with greater than nor- ment when there is a large amount of necrotic debris mal exudate production, wounds that require de- that cannot be surgically debrided, or with excessive bridement or for slow healing wounds (Figure 16. The exudate that are oxygen permeable, impermeable to water and necrotic debris will be mechanically removed and bacteria, allow accumulation of fluid and with daily dressing changes during the first few days exudate under the dressing and are adhesive to nor- of treatment, at which time the type of dressing used mal skin but not wounds. Disadvan- moist, aerobic environment under the dressing pro- tages of wet-to-dry bandages may include tissue mac- motes leukocyte debridement of the wound surface, eration and bacterial colonization with the moist prevents desiccation and scab formation and reduces environment, and disruption of the wound healing 8 pain associated with desiccation of raw nerve end- surface with each dressing change. The dressings are changed every two to three days initially, or more often if excessive exudate production results in fluid leakage from underneath the dressing. Once a Specific Traumatic Injuries healthy granulation bed is established, dressings can be changed weekly. Wounds treated with these dress- and Their Management ings appear to heal more rapidly and with fewer complications compared to conventional non-adher- ent dressings. Lacerations and Abrasions Lacerations and abrasions in companion birds are Secondary Layer commonly caused by enclosure wires, inappropriate The functions of the secondary bandage layer are to toys, collisions during flight, other birds or household absorb fluids and wound exudate, pad the wound pets (Figure 16. Specific management of a lacera- from trauma, and immobilize the wound and under- tion is determined by the size, location and age of the lying fracture during the healing phases. In birds with breast or wing tip lacerations ing gauze material or cast padding is most commonlyl that result from frequent falls, additional therapy used. Tertiary Layer The tertiary or outer layer serves to hold the other layers of the bandages in place. Most bandages con- Band Injuries sist of conforming stretch tapes with or without an m As useful as leg bands are for individual identifica- adhesive. Open style steel birds because they are light-weight and breathable, quarantine bands may cause serious problems if the are well tolerated by most birds, and the material band gap is large enough to allow the bird to get hung adheres to itself cohesively without problems associ- up on the cage wire. In cases where soft tissue bruising, swelling or lacerations, leg fractures or luxa- tions and occasionally death. Even captive-raised birds with closed bands may get their bands caught on toys, clips or enclosure wire (Figure 16. Inappropriately sized bands may cause soft tissue swelling and vascular compromise to the distal leg and toes if young birds outgrow bands that are too small. Some birds on a marginal diet will collect excessive quanti- ties of desquamated skin under a band, resulting in a constrictive injury. The sooner the damaged area is fractures or other injuries may be repaired, the more likely the beak is to heal. If a bird hangs by the leg for prolonged periods, microvascular damage may occur that results Large psittacines may crimp alu- in necrosis 10 to 14 days post-injury. In severe cases, amputation of the most proximal joint minum bands with their beaks, and application of a hydroactive dressing to the stump is necessary. Abrasions and swelling un- the exposed portion with a nail trimmer to make a derneath the band may develop when the leg is ban- smooth surface, and packing ferrous subsulfate or daged. If the keratin sheath of the toe nail has been pulled off Band injuries should be prevented by anticipating to expose the underlying bone, direct pressure should potential problems, especially with open bands that be applied to control hemorrhage. The exposed bone have large gaps and with inappropriately sized can be protected with liquid bandage products,o,p or bands (too small or too large). Once an Beak injuries occur most often from bites from other injury or associated problem with a band is recog- psittacines, or from collisions during flight. Cockatoo nized, extreme caution should be exercised with band males often become extremely aggressive toward the removal to avoid additional injury to the bird. The females, sometimes inflicting lethal injuries (see Chap- owner should always be warned of potential risks to ter 4). Head trauma is common with mate aggression the bird whenever a band is removed, even when the and may be associated with beak fractures, punctures procedure is elective and not associated with trauma. If a wound is already present, avas- controlled with direct digital pressure or by applying cular necrosis may complicate the band removal pro- clotting products such as silver nitrate or ferric subsul- cedure. Many factors may induce self-mutilation behavior Feather, Toenail and Beak Injuries (see Chapters 4 and 24). A thorough diagnostic workup to rule out predisposing factors should be Significant hemorrhage may occur with broken blood considered. Appropriate antibiotic, antifungal or an- feathers, especially broken flight and tail feathers. Di- thelmintic treatment is combined with soft tissue rect digital pressure over the bleeding feather should wound management and protection of the wounds be applied immediately to prevent excessive blood loss. The wounds should be cleansed A first-aid home procedure involves putting flour over and debrided, and surrounding feathers carefully the bleeding feather stub. This conservative treatment plucked or trimmed to prevent them from becoming may be adequate in some cases, but most broken blood matted in the wound. The feather should be help in soothing the pain and irritation caused by grasped at the base with a hemostat (needle-nosed massive self-trauma. Products in- cases of self-mutilation, an Elizabethan collar or neck tended for hemorrhage control during nail and beak brace collar may be indicated to protect the wounds trims, such as silver nitrate and ferric subsulfate from further trauma (Figure 16. The most common thermal burns occur in the crop of Radiocautery should also not be used to blindly cau- neonates fed improperly heated hand-feeding for- terize the interior of a follicle. Further discussion of medical and surgical management of crop burns is covered in Chapter 30. The bird had been treated at Note the numerous emerging pin feathers that many bird owners home with a topical burn ointment. The cause of this bird’s self-mutila- langes were missing, and the foot and leg distal to the mid-meta- tion was undetermined. Because four days had passed since the initial injury, the only effective therapy was amputation may occur when pet birds come in contact with hot of the necrotic limb. The feathers provide some measure of insulation; however, the extent of the trauma depends upon the supportive care including supplemental heat, fluid cause and the duration of exposure. Loss of soft tissue viability may be destruction of the toes or feet, melted beaks or death assessed by discoloration of the skin, loss of (see Color 24). Treatment action to be taken includes neuromuscular control, cooler skin temperature, immediate cooling and rinsing of the affected areas, odor, leakage of serosanguinous fluid and disruption followed by supportive care, topical wound manage- of blood flow to distal extremities. The affected areas should be thoroughly matory condition involving the joint and surrounding washed and the compound neutralized by either so- tissues. Bony changes and reduced function in the dium bicarbonate solution for acidic compounds, or joint may be secondary to trauma, bacterial infection, dilute vinegar for alkaline compounds. Radiographs, microbi- ologic cultures and biopsies are indicated to deter- Frostbite mine the cause and severity of the problem. The prognosis for successful treatment and return to nor- Frostbite injuries are more common in cooler cli- mal joint function is extremely guarded, even with mates, but may occur in warmer regions during un- long-term antibiotic treatment. Injuries may range from mild redness, swelling and pain of the affected digit(s) or limbs, to gangrenous necrosis and death (Figure 16. Sub- strate perch size, shape and covering material may all influence the bird’s weight distribution on the toes and metatarsal pad and the amount of skin wear on the plantar surface. Dry gangrene secondary to frostbite was evident in both legs distal to the tar- sometatarsal joint. Temperatures the week before presentation Bruising and abrasions on the plantar surface of the were below freezing.

The cytosolic Na+ excess discount prograf 5 mg, in 3 turn discount 5 mg prograf amex, drives sarcolemmal Ca2+ inÀux through reverse-mode operation of the sarcolemmal Na+–Ca2+ exchanger purchase prograf 1 mg amex, leading to cytosolic and mitochondrial Ca2+ overload [47] purchase prograf 5 mg overnight delivery, causing a myriad of detrimental effects. Cytosolic Ca2+ overload during ischaemia and reperfusion has been identi¿ed as a primary effector of mitochondrial injury. Mitochondria can sequester large amounts of cytosolic Ca2+, a process regulated by the Ca2+ uniporter for inÀux and by the Na+–Ca2+ exchanger for efÀux [48]. However, as matrix Ca2+ levels progressively rise, the mitochon- drial Na+–Ca2+ exchanger becomes saturated and mitochondrial Ca2+ overload ensues [48]. Mitochondrial Ca2+ overload can worsen cell injury in part by compromising its capability to sustain oxidative phosphorylation [49] and by promoting the release of proapoptotic factors [50]. Mechanisti- cally, these bene¿ts are associated with less cytosolic Na+ overload, less mitochondrial 168 R. Compression depth was adjusted to maintain an aortic diastolic pressure between 26 and 28 mmHg in the ¿rst series and between 36 and 38 mmHg in the second series. Within each series, rats were randomised to receive cariporide (3 mg/kg) or NaCl 0. In rats that received cariporide, the compression depth required to generate a given level of systemic and organ blood Àow was markedly reduced compared with in rats that received the vehicle control. This was the case when cariporide was combined with epinephrine in our pig model [12] and when combined with epinephrine and with vasopressin in our rat model [37]. Rats from the last two time events were randomised to receive Na+-limiting intervention immediately before starting chest com- pression or vehicle control. Limiting sarcolemmal Na+ entry attenuated increases in cytosolic Na+ and mitochondrial Ca2+ overload during chest compression and the postresuscitation phase. After this interval, extracorporeal circulation was started and systemic (extracorporeal) blood Àow adjusted to maintain a coronary perfusion pressure at 10 mmHg for 10min before attempting de¿bril- lation and restoration of spontaneous circulation. The target coronary perfusion pressure was chosen to mimic the low coronary perfusion pressure generated by closed-chest resus- citation. Instead, myocardial tissue measurements indicated that zoniporide administration prevented progressive loss of oxidative phosphorylation during the interval of simulated resuscitation. All these ¿ndings are indicative of preserved mitochondrial bioenergetic function. However, several studies have recently shown that erythropoietin also activates potent cell survival mechanisms during ischaemia and reperfusion through genomic and nongenomic signalling pathways in a broad array of organs and tissues, including the heart [58–63], brain [64, 65], spinal cord [66], retina [67], kidney [68], liver [69] and skin [70]. Although important in other settings, these effects are not likely to play a role for initial cardiac resuscitation. The depth of compression was adjusted to maintain an aortic diastolic pressure between 26 and 28 mmHg. This level of 14 Physiopathology and Severity of Postresuscitation Myocardial Dysfunction 171 diastolic aortic pressure secured a coronary perfusion pressure above the resuscitability threshold of 20 mmHg in rats. This difference represented a 25% improvement in the haemodynamic ef¿cacy of chest compression with erythropoietin given at the beginning of chest compression. However, the protocol was modi¿ed such that the chest was compressed to the maximum depth of 17 mm in rats. Beta-epoetin was kept refrigerated (2–8°C) in the ambulance until immediately before use. However, disrup- tion in the supply of erythropoietin prompted investigators to administer erythropoietin or 0. Post hoc, a second control group was included in which 48 of 126 patients were selected who had out-of-hospital cardiac arrest treated with the same resuscitation protocol the year before. These 48 patients were selected using propensity scores assigning two controls for each erythropoietin-treated patient. Future effort should focus on the translation of these concepts through additional clinical trials that could not only support these ¿ndings but also quantitate their treatment effects paving the way for ultimately clinical implementation. Binak K, Harmanci N, Sirmaci N (1967) Oxygen extraction rate of the myocardium at rest and on exercise in various conditions. Br Heart J 29:422–427 14 Physiopathology and Severity of Postresuscitation Myocardial Dysfunction 173 2. Yusa T, Obara S (1981) Myocardial oxygen extraction rate under general anesthe- sia. Continuous cardiac magnetic resonance imaging during untreated ventricular ¿bril- lation. Ruiz-Bailen M, Aguayo dH, Ruiz-Navarro S et al (2005) Reversible myocardial dysfunction after cardiopulmonary resuscitation. Xu T, Tang W, Ristagno G et al (2008) Postresuscitation myocardial diastolic dys- function following prolonged ventricular ¿brillation and cardiopulmonary resusci- tation. Grmec S, Strnad M, Kupnik D et al (2009) Erythropoietin facilitates the return of spontaneous circulation and survival in victims of out-of-hospital cardiac arrest. Karmazyn M, Sawyer M, Fliegel L (2005) The na(+)/h(+) exchanger: a target for cardiac therapeutic intervention. Imahashi K, Kusuoka H, Hashimoto K et al (1999) Intracellular sodium accumu- lation during ischemia as the substrate for reperfusion injury. Hinokiyama K, Hatori N, Ochi M et al (2003) Myocardial protective effect of lido- caine during experimental off-pump coronary artery bypass grafting. Namiuchi S, Kagaya Y, Ohta J et al (2005) High serum erythropoietin level is as- sociated with smaller infarct size in patients with acute myocardial infarction who undergo successful primary percutaneous coronary intervention. Ghezzi P, Brines M (2004) Erythropoietin as an antiapoptotic, tissue-protective cy- tokine. Celik M, Gokmen N, Erbayraktar S et al (2002) Erythropoietin prevents motor neu- ron apoptosis and neurologic disability in experimental spinal cord ischemic injury. Buemi M, Vaccaro M, Sturiale A et al (2002) Recombinant human erythropoietin inÀuences revascularization and healing in a rat model of random ischaemic Àaps. Li Y, Takemura G, Okada H et al (2006) Reduction of inÀammatory cytokine ex- pression and oxidative damage by erythropoietin in chronic heart failure. Cardio- 14 Physiopathology and Severity of Postresuscitation Myocardial Dysfunction 177 vasc Res 71:684–694 73. Hirata A, Minamino T, Asanuma H et al (2006) Erythropoietin enhances neovascu- larization of ischemic myocardium and improves left ventricular dysfunction after myocardial infarction in dogs. In the United States, every year approximately 300,000 individuals suffer an episode of out-of-hospital sudden cardiac arrest [3]. Efforts to reestablish life are formidably challenging, requiring not only that cardiac activity be reestablished but that injury to vital organs be prevented, minimised, or reversed. Resus- citation methods yield an average survival and hospital discharge rate with intact neuro- logical function that approaches 7. In the United States, ef¿cient emergency medical service systems can initially reestablish cardiac activity in approximately 30% of indi- viduals [7–9] with >40% dying before hospital admission [10]. Of those admitted to hos- pital, nearly 75% die before hospital discharge due to variable degrees of myocardial or neurological dysfunction, systemic inÀammation, intercurrent illnesses, or a combination thereof [10–12]. Thus, initial reestablishment of cardiac activity using available resuscita- tion treatments does not ensure ultimate survival. During cardiac arrest and resuscitation, the myocardium constitutes a prime target of injury, leading to distinct functional abnormalities that can adversely affect resuscitabil- ity and survival. To restore cardiac activity, blood Àow must be ¿rst generated by arti- ¿cial means (e. Reperfusion eventually restores aerobic metabolism, enabling resumption of organ function. However, reperfusion also activates multiple pathogenic mechanisms, known as reperfusion injury, which have been credited with pos- tischaemic cell dysfunction and cell death. At the organ level, reperfusion injury has been linked to the myocardial dysfunction observed after resuscitation from cardiac arrest that leads to dismal survival outcomes. Even though the ¿brillating heart performs no external work, its energy utilisation is comparable with or higher than that of the normally beating heart [16–18]. As a result, cessation of myocardial blood Àow when the heart is ¿brillating leads to severe energy imbalance accompanied – among other effects [19, 20] – by intracellular sodium (Na+) and calcium (Ca2+) overload, which further exacerbate cell injury. The cessation of coro- nary blood Àow during cardiac arrest prompts a shift to anaerobic metabolism in the myocar- dium, leading to rapid development of intense and sustained intracellular acidosis.

An individual case can be reviewed in a very short time buy prograf 5 mg amex, making it ideal for reading on public transportation or when you have only a few minutes cheap prograf 5mg with amex. You can also give the cases a straight read-through buy prograf 5 mg without a prescription, though it’s not as effective as engaging your limbic system a bit by challenging yourself to think buy discount prograf 5 mg line, “What should I do next? Primary textbook references are given, but these should be supplemented by a search for more current literature (using PubMed, UptoDate, or other online research tool). Ask colleagues or mentors about similar cases they’ve encountered and how they managed them. The management decisions in this book are meant to represent “text- book” answers, but real-world management often differs signifcantly. By anchoring your supplemental reading in cases, you will have a greater retention of the manage- ment pearls and other facts discussed. Next, a sample dialogue describes the case as it would be presented by an examiner to a candidate. By looking back and forth between the case and the dialogue, you should get some sense of how the book can be used and how the oral boards are administered. Patient lying on stretcher, appears stated age; appears in mild distress as he attempts to fnd a position of comfort D. Circulation: warm and moist skin, normal pulses, and capillary refll How to Use This Book 5 E. He reports walking to work when he noted a sharp, burning pain in his mid to lower back, worse on the left than the right side. He felt that it radiated up to his posterior chest and down to his leg when it was most pronounced. There is no posi- tion that makes the pain better or worse, and the patient is unable to localize the pain to an exact point on his back. Social: lives with wife; drinks alcohol socially, smokes one-half pack of cig- arettes per day, denies the use of other drugs. Extremities: full range of motion; no deformity; normal femoral, radial, and dorsalis pedis pulses o. Back: nontender, no costovertebral angle tenderness, no muscle spasm, no signs of trauma p. Neurologic: alert and oriented; cranial nerves intact; normal strength, sensation, gait q. Lymphatic: no lymphadenopathy 6 Emergency Medicine Oral Board review illustrated Figure 1. Patient describes worsening of pain, now with nausea and some chest discom- fort as well M. The aorta is the largest artery in the body and carries blood from the heart to the chest and abdomen. Its wall is composed of several layers that can tear, causing blood to dissect in between the layers. High blood pressure, smoking, and chronic medical conditions can increase the risk of this disorder. The patient’s back pain and shortness of breath were due to tearing of the layers of the aorta, and therefore will not be improved with moving to a different position. The aorta should be suspected because of the severity and radiation of pain, and taking into account the patient’s risk factors (smoking) and abnormal vital signs (high blood pressure). If the patient is not placed on a cardiac monitor, they should complain of feeling “woozy. If the patient does not undergo imaging or is discharged, he should lose consciousness. Dissections are often classifed according to their anatomic involvement: Type A involves the ascending aorta; type B does not. The diag- nosis should also be considered for atypical back pain where renal colic or musculoskeletal causes are being considered, especially in patients with risk factors, such as advanced age, smoking, or hypertension. Goals of emergency department therapy for dissection include blood pres- sure reduction and decreasing shear forces acting on the dissection site. Thus, β-blockers such as Esmolol, Metoprolol, and Propranolol are considered frst- line agents. Vasodilators such as sodium nitroprusside may be administered after these agents are used. Analgesia is important for patient comfort; it reduces sympathomimetic drive contributing to blood pressure and shear forces. Surgical management reduces in-hospital mortality for type A dissections and is the standard of care. Initial treatment of type B acute aortic dissections is generally medical (blood pressure control and observation). Patients with persistent pain, uncontrolled hypertension, occlusion of a major arterial trunk, aortic leak or rup- ture, or development of a localized aneurysm may require surgical intervention. Each case will run a very different course depending on the examiner and the choices the candidate makes. This example is intended to highlight a few common circumstances that will come up during the cases. Most cases should take place in an emergency department associated with a large hospital, but you can alter the scenarios as you like. Once you become comfortable with the cases, it will be more interesting and true to the oral board format to act out the case a bit and speak as the patient in the frst person. If all these words are like a foreign language for you, just play the cases straight. Also, note how the candidate has the nurse place a line and draw labs early in the case. Since it is not yet clear which labs will need to be sent, the candidate just requests the nurse “hold” the blood for now. The cases in the rest of the book list lab tests early on, but that doesn’t mean the candidate needs to order them before examining the patient or obtaining a history frst. They are listed early so the examiner has a rough idea of what might be requested or relevant. The retina examination can be described as normal, because the entire eye examination was normal according to the case. Just remember to have the candidate specify what they are examining before giving them the examina- tion results from the case. That’s fne – you have all the answers in front of you and the examiner instructions tell you where the case should go. The candidate, how- ever, may have an easier time if they follow a more algorithmic method of assessing the patient, as described in Chapter 3. This will signifcantly reduce the candidate’s chances of missing something, and it should reduce anxiety on test day. Since the table can’t be split up, show all the laboratory results in the table even if they weren’t all requested. The interpretations are discussed at the end of each case, and a brief interpretation for each fgure in the book is given in Appendix H. When this happens, the consultant will offer no useful information to the candidate, and the candidate will have to continue with the case as they would manage the case on their own. If the candidate is having trouble with some aspect of the case, the consultant can be used to give them a hint. For the purposes of the boards, consultants generally serve to per- form some specifc action that an emergency physician cannot, such as performing an operation, admitting a patient, or performing a specialized study. When asked to give their opinion on a case or provide a diagnosis, they will not be helpful. The radiologist wants to know what you’re looking for so they can protocol the study appropriately. It is read as a dissection of the descending thoracic aorta extending to the abdom- inal aorta and left iliac artery. References should be examined to solidify understanding of the disease processes from the case. Each case will con- tain a reference from “Rosen’s” and “Tintinalli’s,” the formal references are detailed below. It is applicable to our approach in the department and to the more artifcial environment of the board exam.

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