A 3 month old male born full term with no complications presents for a right groin mass. His mother first noticed it two days ago when he cried. Otherwise, he has been acting normally, drinking formula regularly, and having several bowel movements daily. Vital signs and weight are within normal limits for age. Exam shows a happy appearing infant that cries when taken away from his mother. When he cries, a 3 cm soft, non-tender mass is appreciated in the right inguinal region that is easily reducible. There is no overlying erythema or skin changes. Genital exam reveals palpable bilateral testes with no additional masses in the scrotum. Which of the following is the most appropriate management of this condition?

A: admit for observation

B: discharge with expedited surgical follow up

C: discharge with reassurance that it will likely spontaneously resolve

D: emergent surgical consultation

Answer: discharge with expedited surgical follow up

This infant is presenting with a reducible inguinal hernia that increases in size with increased intra-abdominal pressure such as with crying or straining. It is most common in premature males in the first year of life. Unlike in adults, children require surgical referral for interval repair of simple reducible inguinal hernias due to the higher risk of incarceration. Thus, reassurance that it will likely spontaneously resolve without surgical follow up is incorrect. If the hernia was incarcerated, emergent surgical consultation with admission for prompt surgical repair would be appropriate management. 

References:

Fleischman R.J., & Meckler G (2020). Acute abdominal pain in infants and children. Tintinalli J.E., & Ma O, & Yealy D.M., & Meckler G.D., & Stapczynski J, & Cline D.M., & Thomas S.H.(Eds.), Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill.

A 62-year old male with a past medical history of hypertension, hyperlipidemia, and coronary artery disease presents with chest pain. He was discharged from the hospital 2 days ago after being treated for a STEMI which occurred 5 days ago. The pain is mid-sternal, worse with deep inspiration and lying flat. He has been taking all of his medications including aspirin and clopidogrel as instructed. Vital signs are: BP 142/76, HR 102, T 37.2 C, RR 18, SpO2 96%. On exam, he is sitting upright and appears in mild discomfort but otherwise has no focal findings. EKG shows Q waves in II, III, and aVF without significant other changes. POCUS reveals a small circumferential pericardial effusion with a normal ejection fraction. Which of the following is the first line treatment of this patient’s suspected condition?

A: colchicine

B: heparin

C: high dose aspirin

D: naproxen

E: prednisone

Answer: high dose aspirin

This patient is presenting with peri-infarction pericarditis which is an uncommon complication of STEMIs due to the increasing use of reperfusion therapy. Despite not having classic EKG changes suggestive of pericarditis, he meets diagnostic criteria for acute pericarditis. According to the American College of Cardiology and American Heart Association, high dose aspirin (650 mg every 6 hours) is the first line treatment of acute pericarditis after STEMI (Class I recommendation). In contrast to viral, idiopathic, or autoimmune causes of pericarditis, NSAIDs such as naproxen or glucocorticoids are not recommended due to potential for myocardial scar thinning and infarct expansion. Colchicine may be used as an adjunctive medication if high dose aspirin is not effective. Heparin is not recommended for the treatment of acute pericarditis. 

Diagnostic Criteria for Acute Pericarditis (requires 2 of the following)

Characteristic chest pain (sharp or pleuritic, improved sitting up and leaning forward, worse lying down)

Pericardial friction rub

New or worsening pericardial effusion

Suggestive EKG changes (diffuse ST segment elevations)

References:

O’Gara, P. T., Kushner, F. G., Ascheim, D. D., Casey, D. E., Jr, Chung, M. K., de Lemos, J. A., Ettinger, S. M., Fang, J. C., Fesmire, F. M., Franklin, B. A., Granger, C. B., Krumholz, H. M., Linderbaum, J. A., Morrow, D. A., Newby, L. K.,

Ornato, J. P., Ou, N., Radford, M. J., Tamis-Holland, J. E., Tommaso, C. L., … Zhao, D. X. (2013). 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 61(4), e78–e140. https://doi.org/10.1016/j.jacc.2012.11.019

An 18 year old male with a history of type 1 diabetes mellitus presents for a foot wound. He was barefoot playing soccer at a park when he suddenly felt sharp pain on the sole of his right foot and saw a metal nail in the grass. Vital signs are within normal limits. POC glucose is 140. The extremity is neurovascularly intact and shows a subcentimeter puncture wound on the plantar surface with no surrounding erythema or active bleeding. The area is tender to palpation but he is able to ambulate with minimal pain. His tetanus is up to date. In addition to irrigation of the wound, which of the following is most appropriate management for this patient?

A: administer a five-day course of cephalexin

B: administer a five-day course of ciprofloxacin

C: close the wound and discharge the patient

D: discharge with primary care follow up

Answer: administer a five-day course of cephalexin

Antibiotic prophylaxis is recommended for puncture wounds with high-risk features including plantar punctures, bite wounds, heavy contamination, or patients with diabetes or immunosuppression. Most soft tissue infections from puncture wounds are caused by gram-positive organisms. Thus, cephalexin is the most appropriate option listed. Ciprofloxacin would be appropriate if the patient suffered a puncture wound through a shoe as it is thought that pseudomonas colonizes the foam soles. It is generally not recommended to close high risk wounds due to increased risk of infection.

Osteomyelitis
Organism	Association
Staphylococcus aureus	Most common overall
Salmonella sp.	Sickle cell disease
Pseudomonas sp.	Puncture through shoe sole
Pasteurella multocida	Dog and cat bites

References:

Quinn J (2020). Puncture wounds and bites. Tintinalli J.E., & Ma O, & Yealy D.M., & Meckler G.D., & Stapczynski J, & Cline D.M., & Thomas S.H.(Eds.), Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill.

A 28 year old primigravid female at 20 weeks gestation presents for 2 days of vaginal irritation and discharge. Her pregnancy has been uncomplicated, and her only medication is prenatal vitamins. She denies any fever, vomiting, abdominal pain, vaginal bleeding, or dysuria. Vital signs are: HR 92, BP 110/70, T 37.3 C, RR 20, SpO2 98%. Pelvic exam reveals vulvar erythema and white vaginal discharge. Cervical os is closed. Wet mount is shown below. Which of the following is the appropriate treatment?

A: clindamycin vaginal cream

B: clotrimazole vaginal cream

C: PO metronidazole

D: PO fluconazole

Answer: clotrimazole vaginal cream

This patient is presenting with candida vulvovaginitis proven by her wet prep demonstrating budding yeasts and pseudohyphae. Candidal vaginitis infections in pregnant women should be treated with topical azoles. Oral fluconazole is the typical treatment of candida vaginitis in non-pregnant patients but should be avoided in pregnancy due to increased risk for congenital malformations and spontaneous abortion. Clindamycin vaginal cream is an alternative treatment option for bacterial vaginitis. Oral metronidazole is the treatment for either trichomonas or bacterial vaginitis.

Treatment of Vaginitis in Pregnancy
Bacterial	PO metronidazole or vaginal gel Clindamycin vaginal cream
Candida	Topical intravaginal azoles oral azoles contraindicated (category C)
Trichomonas	Metronidazole

References:

Barclay-Buchanan C.J., & Barton M.A. (2020). Vulvovaginitis. Tintinalli J.E., & Ma O, & Yealy D.M., & Meckler G.D., & Stapczynski J, & Cline D.M., & Thomas S.H.(Eds.), Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill.

Mølgaard-Nielsen D, Svanström H, Melbye M, Hviid A, Pasternak B. Association Between Use of Oral Fluconazole During Pregnancy and Risk of Spontaneous Abortion and Stillbirth. JAMA. 2016;315(1):58–67. doi:10.1001/jama.2015.17844

A 25 year old female with an unknown past medical history arrives via EMS for altered mental status. The only history obtained from roommates was that she was found unresponsive on the floor and she was normal yesterday. She was intubated in the field for poor mental status and inability to protect airway. Physical exam shows no evidence of trauma. GCS is E1 V1T M4. Vitals are within normal limits. Head CT shows no evidence of acute intracranial abnormality. Basic metabolic panel results a sodium level of 116. Urine drug screen and urine electrolyte studies are in process. Which of the following is the recommended initial management of her electrolyte derangement at this time?

A: 0.9% normal saline at maintenance rate

B: 1 liter of 0.9% normal saline bolus

C: 150 mL of 3% hypertonic saline over 20 minutes

D: 2 mcg of IV desmopressin

Answer: C. 150 mL of 3% hypertonic saline over 20 minutes

This patient is presenting with acute hyponatremia. The etiology is broad, but in the acute setting, it is most commonly due to excessive water intoxication, psychiatric illness, or substance use. The recommended initial treatment for adult hyponatremic patients with severe neurologic symptoms such as seizures or coma is 100-150 mL of 3% hypertonic saline IV over 15-20 minutes. This may be repeated up to 3 times for an improvement in neurologic status or increase in sodium concentration up to 5 mEq/L. In general, hyponatremic patients should be fluid restricted until differentiating the underlying cause. Thus, 1 liter of normal saline bolus or at maintenance rate is incorrect. A bolus of 1 liter of normal saline may also correct the sodium too quickly, resulting in osmotic demyelination syndrome. Desmopressin is frequently used when hyponatremia is corrected too rapidly in addition to its use in the treatment of diabetes insipidus.

References:
Petrino R, & Marino R (2020). Fluids and electrolytes. Tintinalli J.E., & Ma O, & Yealy D.M., & Meckler G.D., & Stapczynski J, & Cline D.M., & Thomas S.H.(Eds.), Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill.