{"id":2235,"date":"2018-02-05T12:02:56","date_gmt":"2018-02-05T17:02:56","guid":{"rendered":"https:\/\/www.roshreview.com\/?p=2235"},"modified":"2024-02-08T18:18:18","modified_gmt":"2024-02-08T18:18:18","slug":"ep-41-polycythemia-vera-ischemic-hepatitis-hypomagnesemia-chest-tubes-ransons-criteria-emtala-sbp","status":"publish","type":"post","link":"https:\/\/www.roshreview.com\/blog\/ep-41-polycythemia-vera-ischemic-hepatitis-hypomagnesemia-chest-tubes-ransons-criteria-emtala-sbp\/","title":{"rendered":"Podcast Ep 41: Polycythemia Vera, Ischemic Hepatitis &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_41_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\">\n<p class=\"wp-block-paragraph\">We are what we repeatedly do. Excellence, then, is not an act, but a habit.&nbsp;<\/p>\n<cite>\u2013Aristotle<\/cite><\/blockquote>\n\n\n\n<h6 class=\"wp-block-heading\" id=\"h-welcome-back-to-roshcast-for-episode-41-nbsp-as-we-get-closer-and-closer-to-the-in-training-now-would-be-a-great-time-to-go-back-and-listen-to-old-episodes-to-brush-up-on-some-of-the-core-em-knowledge-that-you-may-not-come-across-regularly-on-shift-let-s-get-started-with-a-rapid-review-and-our-regular-mixed-content-of-questions-answers-and-high-yield-review\"><span style=\"font-weight: 400\">Welcome back to RoshCast for Episode 41!&nbsp;As we get closer and closer to the in-training, now would be a great time to go back and listen to old episodes to brush up on some of the core EM knowledge that you may not come across regularly on shift. Let&#8217;s get started with a rapid review and our regular mixed content of questions, answers, and high-yield review.<\/span><\/h6>\n\n\n\n<hr class=\"wp-block-separator has-css-opacity\"\/>\n\n\n<div class=\"wp-block-image\">\n<figure class=\"aligncenter\"><img loading=\"lazy\" decoding=\"async\" width=\"178\" height=\"66\" src=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/RapidReview_50.png\" alt=\"\" class=\"wp-image-1608\"\/><\/figure>\n<\/div>\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Staph aureus<\/strong> is the most common bacterial cause of <strong>septic arthritis<\/strong> in adults.<\/li>\n\n\n\n<li>In a patient with <strong>splenic dysfunction<\/strong>, the <strong>strep species<\/strong> are more likely to cause septic arthritis.<\/li>\n\n\n\n<li>Septic arthritis classically presents with <strong>fever<\/strong>, <strong>monoarticular joint pain<\/strong>, and a <strong>decreased range of motion<\/strong>.<\/li>\n\n\n\n<li><strong>Joint aspirates<\/strong> with a <strong>white count &gt; 50,000<\/strong> with <strong>more than 75% PMNs<\/strong> are indicative of septic arthritis.<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\"><span><b>Now onto this week\u2019s podcast<\/b><\/span><\/p>\n\n\n\n<hr class=\"wp-block-separator has-css-opacity\"\/>\n\n\n\n<p class=\"wp-block-paragraph\"><b>Question 1 <\/b><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span style=\"font-weight: 400\">Which of the following hematological disorders is characterized by intermittent venous and arterial thrombosis, splenomegaly, and abnormal proliferation of all three myeloid cell lines?<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span style=\"font-weight: 400\">A. Aplastic anemia<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span style=\"font-weight: 400\">B. Chronic myelogenous leukemia<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span style=\"font-weight: 400\">C. Disseminated intravascular coagulopathy<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span style=\"font-weight: 400\">D. Polycythemia vera<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/www.roshreview.com\/blog\/wp-content\/uploads\/sites\/2\/2024\/02\/Image-Polycythemia-Vera-@8x.png\" target=\"_blank\" rel=\"noreferrer noopener\">Teaching Image\u00a0<\/a><\/p>\n\n\n\n<hr class=\"wp-block-separator has-css-opacity\"\/>\n\n\n\n<p class=\"wp-block-paragraph\"><b>Question 2<\/b><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span style=\"font-weight: 400\">Which of the following pairs are matched correctly?<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span style=\"font-weight: 400\">A. Elevated direct bilirubin &#8211; Gilbert\u2019s syndrome<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span style=\"font-weight: 400\">B. Elevated indirect bilirubin &#8211; Cholestasis<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span style=\"font-weight: 400\">C. Elevated transaminases with ALT\/AST ratio &gt; 2:1 &#8211; Alcoholic hepatitis<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span style=\"font-weight: 400\">D. Elevated transaminases with AST and ALT &gt; 10,000 IU\/L &#8211; Ischemic hepatitis<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/Ep40_-_ast_alt_alkaline_phosphatase_transaminases_liver_function_tests.png\">Teaching Image&nbsp;<\/a><\/p>\n\n\n\n<hr class=\"wp-block-separator has-css-opacity\"\/>\n\n\n\n<p class=\"wp-block-paragraph\"><b>Question 3<\/b><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span style=\"font-weight: 400\">Which of the following conditions can result in refractory hypokalemia that is not correctable by the administration of potassium?<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span style=\"font-weight: 400\">A. Hypermagnesemia<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span style=\"font-weight: 400\">B. Hypernatremia<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span style=\"font-weight: 400\">C. Hypomagnesemia<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span style=\"font-weight: 400\">D. Hyponatremia<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/Ep41_-_hypomagnesemia_magnesium.png\">Teaching Image<\/a><\/p>\n\n\n\n<hr class=\"wp-block-separator has-css-opacity\"\/>\n\n\n\n<p class=\"wp-block-paragraph\"><b>Question 4<\/b><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span style=\"font-weight: 400\">A 29-year-old man is brought to the ED for a gunshot wound to the right chest. He is diagnosed with a right-sided hemopneumothorax. A tube thoracostomy is subsequently performed with immediate drainage of 250 cc of blood. The nurse connects the chest tube to a commercial suction device, and a chest radiograph is performed that confirms proper placement. You note an absence of respiratory fluctuation of the fluid level in the drainage tube. A repeat chest X-ray shows the right-sided hemothorax remains. Which of the following is true regarding this finding?<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span style=\"font-weight: 400\">A. An air leak is present<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span style=\"font-weight: 400\">B. The lung is still collapsed<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span style=\"font-weight: 400\">C. There is a blockage of the drainage tube<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span style=\"font-weight: 400\">D. This is an expected finding<\/span><\/p>\n\n\n\n<hr class=\"wp-block-separator has-css-opacity\"\/>\n\n\n\n<p class=\"wp-block-paragraph\"><b>Question 5<\/b><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span style=\"font-weight: 400\">Which of the following is true regarding Ranson\u2019s criteria?<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span style=\"font-weight: 400\">A. A score of 0\u20133 on admission constitutes a high-risk population<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span style=\"font-weight: 400\">B. Glucose &gt; 200 mg\/dL on admission is associated with a higher mortality rate<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span style=\"font-weight: 400\">C. Hematocrit &lt; 35% at 48 hours is predictive of mortality<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span style=\"font-weight: 400\">D. WBC &lt; 10,000 is associated with a higher mortality rate<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/Ep41_-_acute_pancreatitis_ranson_s_criteria.png\">Teaching Image&nbsp;<\/a><\/p>\n\n\n\n<hr class=\"wp-block-separator has-css-opacity\"\/>\n\n\n\n<p class=\"wp-block-paragraph\"><b>Question 6<\/b><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span style=\"font-weight: 400\">The Emergency Medical Treatment and Active Labor Law of 1986, or EMTALA, requires hospitals to provide which of the following?<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span style=\"font-weight: 400\">A. Care to all patients <\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span style=\"font-weight: 400\">B. Interpreters for all patients in a timely manner<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span style=\"font-weight: 400\">C. Screening exam, competent ED physicians and appropriate stabilization<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span style=\"font-weight: 400\">D. Screening exam, stabilization process, appropriate transfer process<\/span><\/p>\n\n\n\n<hr class=\"wp-block-separator has-css-opacity\"\/>\n\n\n\n<p class=\"wp-block-paragraph\"><b>Question 7<\/b><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span style=\"font-weight: 400\">A 58-year-old man with a history of cirrhosis presents with abdominal pain and fever. His abdomen is tender to palpation with guarding. You are concerned about spontaneous bacterial peritonitis. You perform a paracentesis and send the ascitic fluid for analysis. Which of the following is most consistent with a diagnosis of spontaneous bacterial peritonitis?<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span style=\"font-weight: 400\">A. Low ascitic fluid glucose concentration <\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span style=\"font-weight: 400\">B. Polymorphonuclear neutrophil count &lt; 250 cells\/mm<\/span><span style=\"font-weight: 400\">3<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span style=\"font-weight: 400\">C. Serum-ascites albumin gradient &lt; 1.1 g\/dL<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span style=\"font-weight: 400\">D. White blood cell count &lt; 1,000 cells\/mm<\/span><span style=\"font-weight: 400\">3<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/Ep41_-_spontaneous_bacterial_peritonitis_sbp.png\">Teaching Image&nbsp;<\/a><\/p>\n\n\n\n<hr class=\"wp-block-separator has-css-opacity\"\/>\n\n\n<div class=\"wp-block-image\">\n<figure class=\"aligncenter\"><img loading=\"lazy\" decoding=\"async\" width=\"178\" height=\"66\" src=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/RapidReview_50.png\" alt=\"\" class=\"wp-image-1608\"\/><\/figure>\n<\/div>\n\n\n<ul class=\"wp-block-list\">\n<li><span style=\"font-weight: 400\"><strong>Polycythemia vera<\/strong> is a <strong>chronic myeloproliferative disorder<\/strong> marked by<strong> increased red blood cell production<\/strong> but can involve all three cell lines.<\/span><\/li>\n\n\n\n<li>Polycythemia vera presents with <strong>pruritus<\/strong>, <strong>especially after bathing<\/strong>, <strong>headaches<\/strong>, <strong>bleeding<\/strong>, <strong>engorged retinal veins<\/strong>, <strong>splenomegaly<\/strong>, and <strong>gout<\/strong>.&nbsp;Treatment is with <strong>serial phlebotomy<\/strong> or with <strong>myelosuppressive agents<\/strong>.<\/li>\n\n\n\n<li><strong>Gilbert\u2019s syndrome<\/strong> is associated with an <strong>elevated indirect bilirubin<\/strong>.<\/li>\n\n\n\n<li><strong> Alcoholic hepatitis<\/strong> is associated with an <strong>AST to ALT ratio of roughly 2:1<\/strong>.<\/li>\n\n\n\n<li>In <strong>ischemic hepatitis<\/strong>, you would expect <strong>elevated transaminases over 10,000<\/strong>.<\/li>\n\n\n\n<li><strong>Hypomagnesemia<\/strong> can result in <strong>refractory hypokalemia<\/strong> not correctable by the <strong>administration of potassium<\/strong>.<\/li>\n\n\n\n<li>Hypomagnesemia can lead to a <strong>prolonged QT<\/strong>, a <strong>widened QRS<\/strong> as well as <strong>atrial and ventricular dysrhythmias<\/strong>.<\/li>\n\n\n\n<li>With respect to <strong>chest tubes<\/strong>, an <strong>air leak<\/strong> occurs when there is <strong>persistent air inside the pleural space<\/strong>.<\/li>\n\n\n\n<li>An absence of <strong>respiratory fluctuation<\/strong> or a <strong>decrease in drainage<\/strong> of a chest tube implies that the system is blocked or the lung is fully expanded.<\/li>\n\n\n\n<li><strong>Ranson\u2019s criteria<\/strong> is a scoring system designed to <strong>predict mortality from acute pancreatitis<\/strong>. <\/li>\n\n\n\n<li><strong>EMTALA,<\/strong> enacted in 1986, is a section of the <strong>Consolidated Omnibus Labor Act<\/strong>. It governs how physicians triage, register, examine, workup, treat and\/or stabilize, discharge or transfer, utilize resources, and involve medical staff expertise when caring for patients who present to the ED.<\/li>\n\n\n\n<li><span><strong>Spontaneous bacterial peritonitis<\/strong> is diagnosed with an <strong>elevated ascitic fluid PMN<\/strong> cell count <\/span><b style=\"font-family: Arial, Helvetica, sans-serif;font-size: 14px;font-style: normal\">over<\/b><span><strong> 250<\/strong> and a <strong>positive ascitic fluid bacterial culture<\/strong>,&nbsp;all in the absence of a secondary cause of peritonitis like a <strong>bowel perforation<\/strong>. SBP is also associated <strong>low ascitic glucose concentrations<\/strong>. It\u2019s treated with a <strong>third-generation cephalosporin<\/strong>.<\/span><\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\"><span style=\"font-weight: 400\">That wraps up RoshCast Episode 41! Don\u2019t forget to follow us on twitter&nbsp;<a href=\"https:\/\/twitter.com\/roshcast?lang=en\">@RoshCast<\/a><\/span><span style=\"font-weight: 400\"><\/span><span style=\"font-weight: 400\"> and <a href=\"https:\/\/twitter.com\/roshreview?lang=en\">@RoshReview<\/a>. We can also be reached by email at <a href=\"mailto:roshcast@roshreview.com\">RoshCast@RoshReview.com<\/a>&nbsp;and are open to any feedback, corrections or suggestions. You can also help us pick questions by identifying ones you would like us to review. To do so, write \u201cRoshcast\u201d in the submit feedback box as you go through the question bank. And finally, if you have a minute, make sure to rate us and leave comments on <a href=\"https:\/\/itunes.apple.com\/us\/podcast\/roshcast\/id1156487141?mt=2\" target=\"_blank\" rel=\"noreferrer noopener\" aria-label=\" (opens in a new tab)\">iTunes<\/a><\/span><span style=\"font-weight: 400\"><\/span><span style=\"font-weight: 400\"> to help spread the word about Roshcast.<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span style=\"font-weight: 400\">Until next time,<\/span><br><span style=\"font-weight: 400\">Jeff and Nachi<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>We are what we repeatedly do. Excellence, then, is not an act, but a habit.&nbsp; \u2013Aristotle Welcome back to RoshCast for Episode 41!&nbsp;As we get closer and closer to the in-training, now would be a great time to go back and listen to old episodes to brush up on some of the core EM knowledge <a href=\"https:\/\/www.roshreview.com\/blog\/ep-41-polycythemia-vera-ischemic-hepatitis-hypomagnesemia-chest-tubes-ransons-criteria-emtala-sbp\/\">read more&#8230;<\/a><\/p>\n","protected":false},"author":11,"featured_media":2236,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"inline_featured_image":false,"footnotes":""},"categories":[2025,1999],"tags":[2081,2111,2117,2197,2200,2258,2287,2368,2385,2431,2590,2600,2652,2719,2732,2757,2845,2904,2920,2921,3057,3082,3321,3323,3338,3342,3353,3381,3391,3436,3442,3443,3448,3455,3524,3525,3563,3565,3566,3573,3581,3742,3778,3781],"coauthors":[3856],"class_list":["post-2235","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-emergency-medicine","category-podcast","tag-acute-pancreatitis","tag-air-leak","tag-alcoholic-hepatitis","tag-ast-to-alt-ratio","tag-atrial-dysrhythmias","tag-bleeding","tag-bowel-perforation","tag-chest-tubes","tag-chronic-myeloproliferative-disorder","tag-consolidated-omnibus-labor-act","tag-emtala","tag-engorged-retinal-veins","tag-fever","tag-gilberts-syndrome","tag-gout","tag-headaches","tag-hypomagnesemia","tag-ischemic-hepatitis","tag-joint","tag-joint-aspirates","tag-monoarticular-joint-pain","tag-myelosuppressive-agents","tag-pleural-space","tag-pmns","tag-polycythemia-vera","tag-positive-ascitic-fluid-bacterial-culture","tag-potassium","tag-prolonged-qt","tag-pruritus","tag-ransons-criteria","tag-red-blood-cell","tag-red-blood-cell-production","tag-refractory-hypokalemia","tag-respiratory-fluctuation","tag-septic-arthritis","tag-serial-phlebotomy","tag-splenic-dysfunction","tag-splenomegaly","tag-spontaneous-bacterial-peritonitis","tag-staph-aureus","tag-strep-species","tag-ventricular-dysrhythmias","tag-white-count","tag-widened-qrs"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v21.7 (Yoast SEO v26.6) - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Podcast Ep 41: Polycythemia Vera, Ischemic Hepatitis &amp; More | RoshReview.com<\/title>\n<meta name=\"description\" content=\"Welcome to RoshCast (Ep. 41), the first question and answer style emergency medicine podcast. 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