Podcast Ep 32: Iron Overdose, Fundal Height, Serotonin Syndrome, & More

Somewhere, something incredible is waiting to be known.

-Sharon Begley

Welcome back to Roshcast Episode 32! We are returning to our regular format – letting the question back randomly generate this week’s material. We will have another collaborative episode with the EM Clerkship podcast soon. We start this episode off with another rapid review based on a recent blog post by Yehuda Wolf. Make sure you keep checking the blog for rapid reviews.

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• Rocky Mountain spotted fever often presents with an abrupt onset of severe headaches, photophobia, vomiting, diarrhea, and myalgias, along with a maculopapular eruption on the patients’ palms and soles.
• Rocky Mountain spotted fever is transmitted by the Dermacentor tick.
• Rocky Mountain spotted fever is treated with doxycycline, even in children.

Now onto this week’s podcast

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Question 1

A 2-year-old boy is brought to the emergency department by his pregnant mother with complaints of hematemesis and bloody diarrhea and an episode of shaking that looked like a seizure. The patient has no past medical history; immunizations are up-to-date. His vital signs are BP 68/32 mm Hg, HR 170 beats per minute, RR 30 breaths per minute, temperature is 36.8°C, and oxygen saturation is 96% on room air. On physical exam, the child appears pale and lethargic. HEENT exam is normal with moist mucosa. His abdomen is nondistended but tender on palpation with active bowel sounds. His skin is cool and clammy. Laboratory results are as follows:

Sodium	137 mEq/L		WBC	17,000/µL
Potassium	5 mEq/L		Platelets	250/µL
Chloride	99 mEq/L		Stool guaiac	Neg
BUN	10 mg/dL		UA	Neg
Creatinine	0.5 mg/dL		UDS	Neg
CO2	16 mg/dL		Serum tox screen	Neg
Glucose	280 mg/dL		aPTT, PT w/INR	Normal

Which of the following arterial blood gases is most consistent with the patient’s diagnosis?

A. pH 7.23, pCO₂ 47, HCO₃20

B. pH 7.33, pCO₂ 32, HCO₃14

C. pH 7.43, pCO₂ 40, HCO₃24

D. pH 7.52, pCO₂ 28, HCO₃24

E. pH 7.55, pCO₂ 33, HCO₃34

Teaching Image

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 Question 2

Where is the uterine fundus palpable at 36 weeks gestation?

A. At the umbilicus

B. At the xiphoid process

C. Between the pubic symphysis and umbilicus

D. Between the umbilicus and xiphoid process

Teaching Image

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Question 3

A 3-week-old boy presents with two days of nonbilious projectile vomiting. Examination reveals a mass in the infant’s right upper quadrant. On a barium upper GI series report, the radiologist states a “string sign” is present. Which of the following is this infant at greatest risk of developing?

A. Hyperchloremia

B. Hyperkalemia

C. Hypokalemia

D. Hyponatremia

Teaching Image

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Question 4

The ultrasound clip above is from an 18-year-old woman with her LMP six weeks ago. Which of the following is associated with this condition?

A. Double decidual sac

B. Fetal heart activity is never identified

C. Relative maternal bradycardia

D. The presence of a gestational and yolk sac on ultrasound

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Question 5

What ultrasound finding is consistent with pulmonary edema?

A. A lines

B. Absence of lung sliding

C. B lines

D. Presence of lung sliding

Teaching Image

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Question 6

A 47-year-old previously healthy man is transferred to your facility in Arizona with acute respiratory distress syndrome and cardiogenic shock. Two days ago, symptoms began with muscle aches, fever, chills, cough, nausea, vomiting, and diaphoresis. Two weeks earlier he was camping in an old, unkempt cabin in the San Rafael Valley, AZ. His two friends who stayed with him eventually began to show similar symptoms. Which of the following tests will confirm the suspected diagnosis?

A. Cardiac biopsy

B. DNA probe for arthroconidia

C. Hantavirus ELISA (IgM)

D. Leptospira spp. serology (IgM)

Teaching Image

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Question 7

A 16-year-old woman arrives to the ED via EMS after she collapsed at a Rave party. Her vital signs are 105.2°F, HR 160 RR 22, and BP 180/100. She is confused, agitated, combative, diaphoretic and has mydriasis. Her reflexes are 4/4 and clonus is noted. Her extremities demonstrate rigidity. Which of the following is the most likely diagnosis?

A. Malignant Hyperthermia

B. Neuroleptic malignant syndrome

C. Serotonin Syndrome

D. Thyrotoxicosis

Teaching Image

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• Iron overdose can cause an anion gap metabolic acidosis. Severe cases can lead to dehydration and shock.
• Iron overdose should be treated supportively. In severe cases, IV deferoxamine can be given.
• The fundal height at 12 weeks is approximately at the pubic symphysis. At 20 weeks, it is at the umbilicus. At 36 weeks, it is at the xiphoid process. And between 37 and 40 weeks, the fundal height regresses slightly.
• Pyloric stenosis can cause a hypochloremic, hypokalemic metabolic alkalosis. Make sure you resuscitate before sending the patient to the operating room.
• Pyloric stenosis presents with bilious, projectile vomiting. It typically occurs between 2 weeks and 2 months of age, and it is more common in males. Diagnosis is made with ultrasound or an upper GI series.
• Hemoperitoneum can lead to relative bradycardia thought to be due to irritation of the vagus nerve.  
• The double decidual sign is a normal finding in early pregnancy. Later in the pregnancy, you can expect to see a gestational and yolk sac in the uterus.
• B lines are indicative of pulmonary edema. A lines are a normal horizontal artifact.
• Absence of lung sliding can be seen in the setting of pneumothorax, apnea, and superficial pneumonias.
• Hantavirus is transmitted by feces and urine from deer mice and is found west of the Mississippi River. It can cause cardiopulmonary disease, renal disease, and hemorrhagic fevers. ECMO can be useful in severe cases.
• Serotonin syndrome presents with fever, tachycardia, hypertension, agitation, and confusion.  Treatment is with benzodiazepines, hydration, and aggressive cooling. MDMA or ecstasy can cause serotonin syndrome.

That wraps up Episode 32. Don’t forget to follow us on Twitter at @Roshcast and @RoshReview. We can also be reached by email at roshcast@roshreview.com. Please send over 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 “Roshcast” 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 iTunes to help spread the word about Roshcast.

Until next time,
Jeff and Nachi