Podcast Ep 41: Polycythemia Vera, Ischemic Hepatitis & More

We are what we repeatedly do. Excellence, then, is not an act, but a habit. 

–Aristotle

Welcome back to RoshCast for Episode 41! 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.

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• Staph aureus is the most common bacterial cause of septic arthritis in adults.
• In a patient with splenic dysfunction, the strep species are more likely to cause septic arthritis.
• Septic arthritis classically presents with fever, monoarticular joint pain, and a decreased range of motion.
• Joint aspirates with a white count > 50,000 with more than 75% PMNs are indicative of septic arthritis.

Now onto this week’s podcast

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Question 1

Which of the following hematological disorders is characterized by intermittent venous and arterial thrombosis, splenomegaly, and abnormal proliferation of all three myeloid cell lines?

A. Aplastic anemia

B. Chronic myelogenous leukemia

C. Disseminated intravascular coagulopathy

D. Polycythemia vera

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Question 2

Which of the following pairs are matched correctly?

A. Elevated direct bilirubin – Gilbert’s syndrome

B. Elevated indirect bilirubin – Cholestasis

C. Elevated transaminases with ALT/AST ratio > 2:1 – Alcoholic hepatitis

D. Elevated transaminases with AST and ALT > 10,000 IU/L – Ischemic hepatitis

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Question 3

Which of the following conditions can result in refractory hypokalemia that is not correctable by the administration of potassium?

A. Hypermagnesemia

B. Hypernatremia

C. Hypomagnesemia

D. Hyponatremia

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Question 4

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?

A. An air leak is present

B. The lung is still collapsed

C. There is a blockage of the drainage tube

D. This is an expected finding

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Question 5

Which of the following is true regarding Ranson’s criteria?

A. A score of 0–3 on admission constitutes a high-risk population

B. Glucose > 200 mg/dL on admission is associated with a higher mortality rate

C. Hematocrit < 35% at 48 hours is predictive of mortality

D. WBC < 10,000 is associated with a higher mortality rate

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Question 6

The Emergency Medical Treatment and Active Labor Law of 1986, or EMTALA, requires hospitals to provide which of the following?

A. Care to all patients

B. Interpreters for all patients in a timely manner

C. Screening exam, competent ED physicians and appropriate stabilization

D. Screening exam, stabilization process, appropriate transfer process

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Question 7

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?

A. Low ascitic fluid glucose concentration

B. Polymorphonuclear neutrophil count < 250 cells/mm3

C. Serum-ascites albumin gradient < 1.1 g/dL

D. White blood cell count < 1,000 cells/mm3

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• Polycythemia vera is a chronic myeloproliferative disorder marked by increased red blood cell production but can involve all three cell lines.
• Polycythemia vera presents with pruritus, especially after bathing, headaches, bleeding, engorged retinal veins, splenomegaly, and gout. Treatment is with serial phlebotomy or with myelosuppressive agents.
• Gilbert’s syndrome is associated with an elevated indirect bilirubin.
• Alcoholic hepatitis is associated with an AST to ALT ratio of roughly 2:1.
• In ischemic hepatitis, you would expect elevated transaminases over 10,000.
• Hypomagnesemia can result in refractory hypokalemia not correctable by the administration of potassium.
• Hypomagnesemia can lead to a prolonged QT, a widened QRS as well as atrial and ventricular dysrhythmias.
• With respect to chest tubes, an air leak occurs when there is persistent air inside the pleural space.
• An absence of respiratory fluctuation or a decrease in drainage of a chest tube implies that the system is blocked or the lung is fully expanded.
• Ranson’s criteria is a scoring system designed to predict mortality from acute pancreatitis.
• EMTALA, enacted in 1986, is a section of the Consolidated Omnibus Labor Act. 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.
• Spontaneous bacterial peritonitis is diagnosed with an elevated ascitic fluid PMN cell count over 250 and a positive ascitic fluid bacterial culture, all in the absence of a secondary cause of peritonitis like a bowel perforation. SBP is also associated low ascitic glucose concentrations. It’s treated with a third-generation cephalosporin.

That wraps up RoshCast Episode 41! Don’t forget to follow us on twitter @RoshCast and @RoshReview. We can also be reached by email at RoshCast@RoshReview.com 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 “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