{"id":1511,"date":"2017-06-07T14:21:32","date_gmt":"2017-06-07T18:21:32","guid":{"rendered":"https:\/\/www.roshreview.com\/?p=1511"},"modified":"2017-06-07T14:21:32","modified_gmt":"2017-06-07T18:21:32","slug":"ep-25-acute-mountain-sickness-ectopic-pregnancy-placental-abruption-boerhaave-syndrome-hyperthyroidism-pcp-pneumonia-and-more","status":"publish","type":"post","link":"https:\/\/www.roshreview.com\/blog\/ep-25-acute-mountain-sickness-ectopic-pregnancy-placental-abruption-boerhaave-syndrome-hyperthyroidism-pcp-pneumonia-and-more\/","title":{"rendered":"Podcast Ep 25: Acute Mountain Sickness, Hyperthyroidism, &amp; More"},"content":{"rendered":"\n<figure class=\"wp-block-audio\"><audio controls src=\"https:\/\/media.blubrry.com\/thereveal\/s\/media.blubrry.com\/roshcast\/s\/content.blubrry.com\/roshcast\/Ep_25_Roshcast_Emergency_Board_Review.mp3\"><\/audio><\/figure>\n\n\n\n<blockquote class=\"wp-block-quote is-layout-flow wp-block-quote-is-layout-flow\"><p>No act of kindness, no matter how small, is ever waster.<\/p><cite>-Aesop<\/cite><\/blockquote>\n\n\n\n<h6 class=\"wp-block-heading\">Welcome back to Episode 25\u2014our silver anniversary episode! It was great connecting with a few listeners recently at SAEM. At the beginning of this week\u2019s episode, we announced a new contest \u2013 be the first to tweet to us (<a href=\"https:\/\/twitter.com\/roshcast\">@Roshcast<\/a>) or email (<a href=\"mailto:Roshcast@roshreview.com)\">Roshcast@roshreview.com)<\/a> the exact time in episodes 26-30 that you hear a trauma phone ring tone to win a 30-day subscription to Rosh Review! First, let us get started with a rapid review covering fish poisonings.<\/h6>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<div class=\"wp-block-image\"><figure class=\"aligncenter\"><img loading=\"lazy\" decoding=\"async\" width=\"201\" height=\"74\" src=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/RapidReview-2-e1475624722961.png\" alt=\"\" class=\"wp-image-818\" \/><\/figure><\/div>\n\n\n\n<ul class=\"wp-block-list\"><li><strong>Hot and cold sensation reversal<\/strong> is classically associated with <strong>ciguatera poisoning<\/strong>.<\/li><li>In <strong>scombroid poisonings<\/strong>, patients have reported a <strong>metallic<\/strong>, <strong>bitter<\/strong>, or even <strong>peppery taste.<\/strong><\/li><li>In <strong>scombroid poisonings<\/strong>, <strong>histidine<\/strong> is broken down into <strong>histamine<\/strong>. Treat patients supportively with <strong>antihistamines<\/strong>.<\/li><\/ul>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Now onto this week&#8217;s podcast<\/strong><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Question<\/strong><strong> 1<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">You are on a 10-day mountain climbing excursion in Colorado with one of your 55-year-old coworkers. After ascending to an altitude of 9200 feet, your coworker develops a mild bifrontal headache associated with nausea. He reports feeling \u201chung over\u201d but denies drinking any alcohol the previous night. He has no other symptoms. On examination, there are no focal neurologic deficits. He desires to continue the climb. Which of the following is the most appropriate next step in the management of your coworker?<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>A. Administer acetazolamide<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>B. Administer dexamethasone<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>C. Arrange to be airlifted to a lower altitude<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>D. Continue to ascend but at a slower rate<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/Ep25-Acute-Mountain-Sickness.jpeg\">Teaching Image<\/a><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Question<\/strong><strong> 2<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A 27-year-old woman, G2P1, presents with vaginal bleeding and right lower quadrant pain. She reports a positive pregnancy test and LMP 6 weeks prior to her evaluation. Vital signs are T 98.6\u00b0F, BP 110\/68, HR 72, and RR 16. Her abdomen is soft with mild tenderness in the right pelvic area. Pelvic examination is notable for a small amount of red blood in the vagina and mild right adnexal tenderness. Bedside ultrasound shows an empty uterus and adjacent to the right ovary a gestational sac with yolk sac and fetal pole. Which of the following is a contraindication to methotrexate administration?<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>A. Fetal heart activity<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>B. Gestational sac greater than 2.5 cm in diameter<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>C. hCG level of 3000<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>D. History of ectopic pregnancy<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/Ep25-Methotrexate-Ectopic.jpeg\">Teaching Image<\/a><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Question<\/strong><strong> 3<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A 32-year-old woman, G2P1, at 33 weeks gestation presents to the emergency room for sharp abdominal pain. She has not had any prenatal care during this pregnancy. Her symptoms include vaginal bleeding, uterine pain between contractions, and fetal distress. Her first pregnancy was uncomplicated, with a vaginal delivery at term. Which one of the following is the most likely diagnosis?<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>A. Placenta previa<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>B. Placental abruption<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>C. Uterine rupture<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>D. Vasa previa<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/Ep25-Placental-Abruption.jpeg\">Teaching Image<\/a><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Question<\/strong><strong> 4<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Perforation of which&nbsp;gastrointestinal structure is associated with the highest mortality?<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>A. Cecum<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>B. Duodenum <\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>C. Esophagus<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>D. Stomach<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/Ep25-Boerhaave-Syndrome.jpeg\">Teaching Image<\/a><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Question<\/strong><strong> 5<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">An 18-year-old woman presents with fever, confusion, weight loss, and palpitations. Her vital signs are T 100.7\u00b0F, HR 140, BP 143\/93, RR 20, oxygen saturation 95%, and finger stick glucose of 118. Physical examination reveals a thin woman who is alert and oriented x3 with a regular, fast heart rate, and brisk reflexes. Her roommate tells you that the patient has been taking a friend\u2019s levothyroxine in an attempt to lose weight. What management should be initiated?<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>A. Beta-blocker <\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>B. Beta-blocker, dexamethasone<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>C. Beta-blocker, dexamethasone, propylthiouracil, and potassium iodide<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>D. Calcium channel blocker, dexamethasone<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/Table-Pharmaceutical-Management-of-HyperthyroidismThyroid-Storm.png\">Teaching Image<\/a><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Question<\/strong><strong> 6<\/strong><\/p>\n\n\n\n<div class=\"wp-block-image\"><figure class=\"aligncenter\"><img loading=\"lazy\" decoding=\"async\" width=\"344\" height=\"397\" src=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/Image-PJP-Pneumonia.jpg\" alt=\"\" class=\"wp-image-1427\" srcset=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/sites\/2\/Image-PJP-Pneumonia.jpg 344w, https:\/\/www.roshreview.com\/wp-content\/uploads\/sites\/2\/Image-PJP-Pneumonia-260x300.jpg 260w\" sizes=\"auto, (max-width: 344px) 100vw, 344px\" \/><\/figure><\/div>\n\n\n\n<p class=\"wp-block-paragraph\">A 53-year-old man complains of fever and non-productive cough. He is also short of breath with exertion. His X-ray is shown above. Which test will be an important part of his overall evaluation?<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>A. HIV antibody<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>B. Purified protein derivative skin test<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>C. Urine <em>Histoplasma<\/em> antigen<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>D. Urine <em>Legionella<\/em> antigen<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/Image-PCP-Pneumonia-Pneumocystis-Pneumocystis-jiroveci-Pneumonia-1.png\">Teaching Image<\/a><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<div class=\"wp-block-image\"><figure class=\"aligncenter\"><img loading=\"lazy\" decoding=\"async\" width=\"201\" height=\"74\" src=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/RapidReview-2-e1475624722961.png\" alt=\"\" class=\"wp-image-818\" \/><\/figure><\/div>\n\n\n\n<ul class=\"wp-block-list\"><li><strong>Acute mountain<\/strong> <strong>sickness<\/strong> is characterized by <strong>headache<\/strong>, <strong>nausea<\/strong>, <strong>dizziness<\/strong>, and <strong>sleep disturbances<\/strong> after <strong>rapid ascent<\/strong> of an unacclimatized person at <strong>2000 meters <\/strong>or higher.<\/li><li><strong>Mild<\/strong> <strong>acute mountain sickness<\/strong> should be treated first by <strong>halting ascent<\/strong> and then supportively with <strong>fluids<\/strong>,<strong> oxygen<\/strong>,<strong> analgesia<\/strong>, and <strong>anti-emetics<\/strong>. <strong>Acetazolamide<\/strong> and <strong>dexamethasone<\/strong> can be used as a <strong>second-line agent<\/strong>.<\/li><li>When medically managing an <strong>ectopic pregnancy<\/strong>, <strong>methotrexate<\/strong> is <strong>relatively contraindicated<\/strong> when <strong>fetal heart activity is present<\/strong>, and <strong>contraindicated<\/strong> with <strong>hemodynamic instability<\/strong> or <strong>evidence of rupture<\/strong> on ultrasound. To be eligible for the treatment you need to have a <strong>gestational sac less than 3.5 cm<\/strong> and be able and willing to <strong>comply with post-treatment monitoring.<\/strong><\/li><li><strong>Risk<\/strong> <strong>factors<\/strong> for an <strong>ectopic pregnancy<\/strong> include <strong>prior ectopic pregnancies<\/strong>, <strong>history of<\/strong> <strong>PID<\/strong>,<strong> tubal surgery<\/strong>, or an <strong>IUD<\/strong>.<\/li><li>The <strong>fallopian tube<\/strong> is the most common location of an <strong>ectopic pregnancy<\/strong>.<\/li><li><strong>Interstitial ectopic<\/strong> <strong>pregnancies<\/strong> occur with <strong>implantation<\/strong> of the developing fetus in the <strong>interstitium of the myometrium<\/strong>. In such cases, the <strong>sac<\/strong> may have an <strong>eccentric appearance<\/strong> on <strong>sonography<\/strong>, but there would be a <strong>thin endomyometrial mantle<\/strong>.<\/li><li><strong>Placental abruption<\/strong> typically manifests as <strong>painful vaginal bleeding<\/strong> with evidence of <strong>fetal distress<\/strong> in the <strong>third trimester<\/strong>. Often the <strong>fundus will be tender<\/strong> and the patient will likely have <strong>pain between contractions<\/strong>.<\/li><li>Common<strong> risk factors<\/strong> for <strong>placental abruption<\/strong> include <strong>abdominal trauma<\/strong>, <strong>maternal<\/strong> <strong>hypertension<\/strong>, <strong>smoking<\/strong>, <strong>cocaine use<\/strong>, <strong>multiple gestation<\/strong>, and <strong>previous abruption<\/strong>.<\/li><li><strong>Uterine rupture<\/strong> classically presents with a <strong>sudden tearing uterine pain<\/strong> <strong>with contractions<\/strong> with pain free intervals between contractions.<\/li><li><strong>Placenta previa<\/strong> usually manifests as <strong>painless vaginal bleeding<\/strong> in the <strong>late 2<sup>nd<\/sup> or 3<sup>rd<\/sup> trimesters<\/strong> due to <strong>placental tissue overlying<\/strong> the internal <strong>cervical<\/strong> <strong>os<\/strong>.<\/li><li><strong>Vasa previa<\/strong> occurs when the <strong>umbilical cord<\/strong> <strong>inserts<\/strong> into the membranes of the <strong>lower uterine<\/strong> <strong>segment<\/strong> and amniotic blood vessels present in front of the fetal head. This usually <strong>presents<\/strong> <strong>with hemorrhage after amniotomy<\/strong> <strong>or spontaneous rupture of membranes<\/strong>.<\/li><li><strong>Esophageal rupture<\/strong> carries <strong>significant morbidity<\/strong> and mortality. It should be treated with <strong>immediate antibiotics<\/strong> and a <strong>surgical consultation<\/strong>.<\/li><li>More than 90% of <strong>spontaneous esophageal ruptures<\/strong> occur in the <strong>distal esophagus<\/strong>.<\/li><li>With <strong>blunt trauma<\/strong> to the neck or thorax, <strong>esophageal rupture<\/strong> is usually in the <strong>proximal<\/strong> <strong>or<\/strong> <strong>middle third<\/strong> of the esophagus. <strong>Iatrogenic injuries<\/strong> frequently occur at the <strong>pharyngoesophageal<\/strong> <strong>junction<\/strong>.<\/li><li><strong>Endogenous thyroid storm<\/strong> is treated with <strong>beta-blockers<\/strong>, <strong>PTU<\/strong>, <strong>potassium iodide,<\/strong> and <strong>dexamethasone<\/strong>. <strong>Exogenous thyroid storm<\/strong> is treated with <strong>beta-blockers<\/strong> and <strong>dexamethasone<\/strong>.<\/li><li>In thyroid storm, <strong>propranolol<\/strong> <strong>reduces peripheral conversion of T4 to<\/strong> <strong>T3<\/strong>. <strong>PTU<\/strong> <strong>blocks<\/strong> <strong>synthesis of thyroid hormone<\/strong>.<\/li><li><strong>Potassium iodide<\/strong> <strong>blocks<\/strong> <strong>the<\/strong> <strong>release of thyroid hormone<\/strong>. <strong>Dexamethasone<\/strong> <strong>blocks<\/strong> the <strong>peripheral conversion of T4 to T3<\/strong> in addition to <strong>treating the relative adrenal insufficiency<\/strong>.<\/li><li><strong>PJP<\/strong>, formerly PCP pneumonia, is typically seen in those who are <strong>immunocompromised<\/strong>.&nbsp;The x-ray will have <strong>bilateral interstitial infiltrates<\/strong> in a <strong>bat wing<\/strong> configuration. If the <strong>PaO2 is less<\/strong> <strong>than 70<\/strong> <strong>or<\/strong> the <strong>A-a gradient is greater than 35<\/strong>, <strong>treat with steroids<\/strong> in addition to <strong>trimethoprim-sulfamethoxazole<\/strong>.<\/li><\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">So, that wraps up Episode 25. Do not forget to listen for the trauma phone ring tone in the coming weeks for a chance to win a Rosh Review Subscription. Remember to tweet (<a href=\"https:\/\/twitter.com\/roshcast\">@Roshcast<\/a>) or email (<a href=\"mailto:Roshcast@roshreview.com)\">Roshcast@roshreview.com)<\/a> the exact time you hear the ring to win the prize.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Until next time,<br>Jeff and Nachi<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Welcome back to Episode 25 &#8212; our silver anniversary episode! It was great connecting with a few listeners recently at SAEM. At the beginning of this week\u2019s episode, we announced a new contest \u2013 be the first to tweet to us (@Roshcast) or email (Roshcast@roshreview.com) the exact time in episodes 26-30 that you hear a trauma phone ring tone to win a 30-day subscription to Rosh Review! First, let us get started with a rapid review covering fish poisonings.<\/p>\n","protected":false},"author":11,"featured_media":1541,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"inline_featured_image":false,"footnotes":""},"categories":[2025,1999],"tags":[2041,2066,2078,2089,2137,2145,2160,2195,2225,2238,2250,2315,2387,2407,2500,2526,2557,2558,2595,2604,2620,2625,2638,2698,2713,2755,2757,2805,2806,2808,2810,2861,2892,2910,2958,2964,3007,3028,3031,3068,3086,3091,3150,3182,3197,3198,3275,3298,3312,3316,3317,3318,3337,3354,3357,3384,3386,3408,3511,3541,3545,3550,3580,3654,3655,3669,3685,3688,3697,3721,3736],"coauthors":[],"class_list":["post-1511","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-emergency-medicine","category-podcast","tag-abdominal-trauma","tag-acetazolamide","tag-acute-mountain-sickness","tag-adrenal-insufficiency","tag-amniotomy","tag-analgesia","tag-anti-emetic","tag-ascent","tag-batwing","tag-beta-blocker","tag-bitter","tag-calcium-channel-blocker","tag-ciguatera","tag-cocaine-use","tag-dexamethasone","tag-dizziness","tag-ectopic","tag-ectopic-pregnancy","tag-endogenous-thyroid-storm","tag-environmental","tag-esophageal-rupture","tag-exogenous-thyroid-storm","tag-fallopian-tube","tag-gastroenterology","tag-gi","tag-hcg","tag-headaches","tag-histamine","tag-histidine","tag-histoplasma","tag-hiv","tag-immunocompromised","tag-interstitial-infiltrate","tag-iud","tag-legionella","tag-levothyroxine","tag-maternal-hypertension","tag-metallic","tag-methotrexate","tag-multiple-gestation","tag-myometrium","tag-nausea","tag-obstetrics","tag-oxygen","tag-painful-vaginal-bleeding","tag-painless-vaginal-bleeding","tag-peppery","tag-pharyngoesophageal-junction","tag-pid","tag-pjp-pneumonia","tag-placenta-previa","tag-placental-abruption","tag-poisoning","tag-potassium-iodide","tag-ppd","tag-propranolol","tag-propylthiouracil","tag-ptu","tag-scombroid","tag-sleep-disturbance","tag-smoking","tag-sonography","tag-steroids","tag-thyroid-hormone","tag-thyroid-storm","tag-toxicology","tag-trimethoprim-sulfamethoxazole","tag-tubal-surgery","tag-ultrasound","tag-uterine-rupture","tag-vasa-previa"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v28.4 (Yoast SEO v28.6) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>Podcast Ep 25: Acute Mountain Sickness, Hyperthyroidism &amp; More | RoshReview.com<\/title>\n<meta name=\"description\" content=\"Welcome to RoshCast (Ep. 25), the first question and answer style emergency medicine podcast. 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