QUESTION: A mother brings her full-term 3-day-old male newborn to the ED after she noticed an episode of dark tarry stool at home. Mom delivered the newborn vaginally without any complications. Mom is a vegetarian and is breastfeeding. On exam, the patient is afebrile. His abdomen is soft with no palpable masses. Rectal exam reveals dark tarry stool that is guaiac positive. Which of the following is the most likely cause of this patient’s presentation?
A. Meckel’s diverticulum
B. Milk protein allergy
C. Necrotizing enterocolitis
D. Swallowed maternal blood
In the neonatal period, the most likely cause of lower gastrointestinal bleeding is swallowed maternal blood, either from delivery or cracked nipples during breast-feeding. The Apt test differentiates fetal from maternal blood. The blood in question is mixed with alkali to detect conversion of oxyhemoglobin to hematin. Fetal hemoglobin is more resistant to denaturation than adult hemoglobin. If the supernatant stays pink after addition of alkali, the blood is fetal in origin (a positive test). This should not be confused with the Kleihauer-Betke test, used to detect fetal-maternal hemorrhage in the pregnant female.
Necrotizing enterocolitis (C) is a complication of premature infants and presents with abdominal distension, bloody stools, and feeding intolerance. Milk protein allergy (B) should be suspected after introduction of a new formula. Infants who are breastfed are not immune to this condition if mom consumes cow’s milk in her diet. Since the mother in this vignette is a vegetarian and is breast-feeding, it is unlikely that a milk protein allergy is responsible for the patient’s guaiac positive stool. In older infants with painless hematochezia, congenital malformations such as small intestine duplication and Meckel’s diverticulum (A) should be considered. Meckel’s diverticulum is most common at 2 years of age.
Kharbanda AB, Sawaya RD: Acute Abdominal Pain in Children, in Tintinalli JE, Stapczynski JS, Ma OJ, et al (eds): Tintinalli’s Emergency Medicine, ed 7. New York, The McGraw-Hill Companies Inc., 2011, (Ch) 124:p 839-854
#2QUESTION: Which of the following conditions is associated with ascending weakness?
B. Ciguatera poisoning
C. Miller-Fisher variant of Guillain-Barre syndrome
D. Tick paralysis
Tick paralysis usually occurs in the spring and summer months, and most often in young children, especially girls as their long hair conceals the embedded tick. Tick paralysis occurs when the female tick attaches to a host and releases a neurotoxin that can produce cerebellar dysfunction or ascending paralysis. Symptoms begin 4 to 7 days after the tick attaches. Initial manifestations include restlessness and irritability, followed by ascending flaccid paralysis, acute ataxia, or a combination of the two. Deep tendon reflexes are almost always lost. Treatment consists of simply removing the tick. Improvement is seen typically within a few hours and complete recovery within 48 hours.
Botulinum toxin (A) binds to the presynaptic terminus of neuromuscular and autonomic synapses resulting in a decrease of acetylcholine release. Flaccid paralytic symptoms ensue, first in a bulbar distribution then descending. Ciguatera poisoning (B) is associated with ingestion of ciguatoxin, a substance with anticholinesterase and cholinergic properties that also lowers the threshold for opening of voltage-gated sodium channels. The latter results in depolarization and heightened neurologic response with symptoms that include dyesthesias and paresthesias around the throat and perioral area, a burning sensation in the feet and distortion of temperature sensation. The Miller-Fisher variant of Guillian Barre syndrome (C) is associated with a descending paralysis. It usually affects the eye muscles first and presents with the triad of ophthalmoplegia, ataxia, and areflexia. The ataxia predominantly affects the gait and trunk, with the limbs relatively spared.
Bolgiano EB, Sexton, J: Tick-Borne Illnesses, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 7. St. Louis, Mosby, Inc., 2010, (Ch)132:p 1791-1792
QUESTION: A 60-year-old woman presents to the ED with two days of right upper quadrant abdominal pain that is constant in nature and associated with subjective fever, nausea, and vomiting. Vital signs are temperature of 100.6°F, heart rate 87, blood pressure 140/80 mm Hg, respiratory rate 14, and O2 saturation of 99% on room air. Her abdomen is soft with right upper quadrant tenderness and a positive Murphy’s sign. Which of the following tests is most sensitive and specific in diagnosing this patient’s condition?
A. Computed tomography scan with intravenous contrast
B. Hepatobiliary iminodiacetic acid (HIDA) scan
C. MRI with gadolinium
This patient has suspected acute cholecystitis and requires an imaging study for confirmation. Hepatobiliary iminodiacetic acid (HIDA) scanning is considered to be the most sensitive and specific test for diagnosing acute cholecystitis. IDA is administered intravenously, taken up by hepatocytes, and excreted into the bile canaliculi. Failure to obtain an outline of the gallbladder within 1 hour proves cystic duct obstruction and, in the appropriate clinical setting confirms the diagnosis of acute cholecystitis. Visualization of the gallbladder and common duct within 1 hour has a high negative predictive value. A HIDA scan is usually obtained when the ultrasound study is equivocal.
Computed tomography scan with intravenous contrast (A) can identify cholecystitis with a reported sensitivity of 92% and specificity of 99%. It is most useful in cases of emphysematous and hemorrhagic cholecystitis. MRI with gadolinium (C) provided similar diagnostic yield to CT scan. Ultrasound (D) is most useful in the ED setting as it is a quick, non-invasive test. Its sensitivity and specificity, however, are lower than a HIDA scan for pathology confirmed cholecystitis. Ultrasound findings and a clinical exam consistent with acute cholecystitis are highly predictive and many such patients will undergo cholecystectomy without any further diagnostic testing.
Guss DA, Oyama LC: Disorders of the Liver and Biliary Tract, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 7. St. Louis, Mosby, Inc., 2010, (Ch) 88:p 1153-1171
QUESTION: Which lab marker elevation has the highest predictability for a biliary etiology in patients diagnosed with acute pancreatitis?
A. Alanine aminotransferase (ALT)
B. Aspartate transaminase (AST)
D. Total bilirubin
Elevation in liver enzymes may result from biliary-induced pancreatitis, particularly when pressure from surrounding pancreatic inflammation impinges the common bile duct. Alanine aminotransferase (ALT) is the best single marker for a biliary etiology. Levels 3 times greater than baseline support the diagnosis of biliary pancreatitis. The higher the level of ALT, the greater the specificity and predictive value for gallstones. ALT levels more than 150 IU/L have 96% specificity and 95% positive predictive value for gallstone pancreatitis.
According to Ranson’s criteria, an elevated aspartate transaminase (AST) (B) is associated with a worse prognosis in patients with pancreatitis. An elevated AST, especially when greater than corresponding ALT level, is commonly seen in patients with alcoholic but not biliary pancreatitis. Elevated lipase (C) is specific for acute pancreatitis. At values 5 times the upper limit of normal, lipase is 60% sensitive and 100% specific. Mild elevations of bilirubin (D) are common in all types of pancreatitis (as well as many other liver disorders) and are not predictive of a biliary etiology.
Hemphill RR, Santen SA: Disorders of the Pancreas, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 7. St. Louis, Mosby, Inc., 2010, (Ch) 89:p 1177.
QUESTION: A 34-year-old man presents to the ED with acute onset of chest palpitations. He is placed on the cardiac monitor and you note a supraventricular tachycardia with a rate of 185 beats per minute. The patient is hemodynamically stable. He states that this happened in the past and the doctors gave him a drug through the IV that made him feel horrible, but it treated his condition. In the presence of the medications listed below, which one will require you to increase the dose of adenosine used in this patient?
Adenosine has an excellent safety profile and is often the drug of choice to treat hemodynamically stable patients with a narrow complex paroxysmal supraventricular tachycardia. It has an ultra-short half life (<10 secs) and lacks the vaso- and myocardial depressant effects of some other AV nodal agents. Although it produces side effects (flushing, dyspnea, and chest pain), they are transient. Adenosine has several drug interactions. Its effects are antagonized by the methylxanthines (theophylline, caffeine) since methylxanthines prevent binding of adenosine at receptor sites. Therefore large doses of adenosine may be required in the presence of methylxanthines.
Dipyridamole (D), carbamazepine (B), and diazepam (C) potentiate the effects of adenosine therefore smaller doses (or an alternative agent) should be used with these medications. There is no interaction with aspirin (A) that requires a dosing change in adenosine.
Yealy DM, Delbridge TR: Dysrhythmias, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 7. St. Louis, Mosby, Inc., 2010, (Ch) 77:p 994
Parsons WJ, Stiles GL. Methylxanthines as Adenosine Receptor Antagonists. Ann Inn Med. 1985;103(4):643
QUESTION: A 49-year-old man with a history of hypertension presents to the ED with one day of vomiting and diarrhea. The patient states that his whole family is sick with the same illness. You administer an antiemetic and orally rehydrate the patient. He feels much better and is ready to be discharged. The nurse obtains vital signs prior to discharge that reveals a blood pressure of 175/95 mm Hg. Which of the following is the most appropriate next steps in management?
A. Discharge the patient
B. Obtain an ECG
C. Order a CBC
D. Order a urine drug screen
The Emergency Medicine Cardiac Research and Education Group (EMCREG) recommends no ancillary testing on asymptomatic, healthy patients with a blood pressure reading greater than 160/100 mm Hg as it typically does not impact acute management. This patient, with a history of hypertension, has an asymptomatic elevation of his blood pressure which does not need to be treated in the ED. He can be safely discharged without further testing but should follow up with a primary care provider within 1 week to 1 month.
Findings on ECG may be abnormal in the setting of prolonged hypertension. In a patient where there is concern for ischemia (ie chest pain, dyspnea), an ECG should be obtained; however, in an asymptomatic, otherwise healthy patient, an ECG (B) is of limited utility. There is no evidence to support obtaining a routine CBC (C) in patients with asymptomatic hypertension. A urine drug screen (D) cannot discern exposure of the drug from acute intoxication and therefore serves no utility.
Hoekstra J, Qureshi A. Management of hypertension and hypertensive emergencies in the emergency department: the EMCREG-international consensus recommendations. Ann Emerg Med. 2008;51(3):S1-S38.
QUESTION: Which of the following findings is most specific for the diagnosis of acute decompensated heart failure?
B. Jugular venous distension
Unlike myocardial infarction or pulmonary edema, the diagnosis of acute heart failure syndrome can be elusive. History and physical exam are not always accurate when attempting to establish the diagnosis. However,the best physical exam finding suggestive of an elevated pulmonary capillary wedge pressure is the S3 heart sound, with a specificity of 99%.
Dyspnea (A) has a sensitivity and specificity 50%. Jugular venous distension (B) has a specificity of 94% and a sensitivity of 39%. Orthopnea (C) has a specificity of 88%.
Peacock WF: Congestive Heart Failure and Acute Pulmonary Edema, in Tintinalli JE, Kelen GD, Stapczynski JS (eds): Emergency Medicine, A Comprehensive Study Guide, ed 7. New York, McGraw-Hill, 2011, (Ch) 57:p 405-414.
QUESTION: A 47-year-old woman with a history of hypertension presents to the ED with a severe headache that began suddenly 3 hours prior to arrival. She has a history of recurrent frontal headaches for the last month and is currently being treated for a migraine headache. Today, she also complains of blurry vision, diplopia, nausea, vomiting, and confusion. Her vital signs are BP 95/45 mm Hg, HR 118, RR 23, T 98.2°F, and pulse oximetry of 98% on room air. On exam, she appears somnolent. Neurologic exam reveals a dilated, minimally reactive left pupil, a globe that is deviated inferiorly, and bitemporal hemianopsia. Lab results only reveal hyponatremia of 129. Normal saline is administered and a CT scan reveals an intraseller mass. Which of the following is an appropriate step in the management of this patient?
A. Administer intravenous 3% saline
B. Administer intravenous hydrocortisone
C. Administer intravenous mannitol
D. Arrange for rapid radiation therapy
The patient has pituitary apoplexy from a pituitary tumor. The initial symptoms of pituitary apoplexy are related to the increased pressure in and around the pituitary gland. The most common symptom, in over 95% of cases, is a sudden-onset headache located behind the eyes or around the temples. It is often associated with nausea and vomiting. The patient’s clinical presentation is also consistent with acute (secondary) adrenal insufficiency due to inadequate ACTH production from the pituitary gland. Adrenal insufficiency manifests in this patient as hypotension, fatigue, abdominal pain, and hyponatremia. It is also associated with hyperkalemia, and hypoglycemia. Hydrocortisone is the preferred steroid to administer because it provides both glucocorticoid and mineralcorticoid effects. Clinical improvement is usually seen within few hours of steroid administration.
Intravenous 3% saline (hypertonic saline) (A) is most commonly reserved for cases of acute hyponatremia associated with neurologic abnormalities. Intravenous mannitol is an osmotic agent used as a therapy to temporarily reduce intracranial pressure. The patient’s symptoms are due to compression of a pituitary tumor on the optic nerve. Mannitol (C) is not going to relieve this process. Radiation therapy (D) has no role in the acute setting. Treatment is surgical and generally requires transsphenoidal surgery.
Zull D: Thyroid and Adrenal Disorders, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 7. St. Louis, Mosby, Inc., 2010, (Ch) 126:p 1671-1675
QUESTION: Which of the following is correct regarding the condition seen in the image above?
A. Involvement of the scalp and nails is uncommon
B. It is associated with the Auspitz sign
C. Lesions most commonly occur on flexor surfaces
D. Systemic steroids are the preferred treatment
The well-demarcated erythematous plaques and papules with silvery white scales are characteristic of psoriasis. Removal of the scale typically reveals pinpoint-bleeding areas referred to as the Auspitz sign. There is a hereditary predilection for the condition and it often begins in the second or third decade of life.
Lesions tend to be symmetric and are most commonly found on the trunk, scalp, nails (A), and extensor surfaces (C). Systemic steroids (D) should be avoided due to the risk of developing rebound or induction of pustular psoriasis.
Hess MR, Hess SP: Skin Disorders Common on the Trunck, in Tintinalli JE, Kelen GD, Stapczynski JS (eds): Emergency Medicine, A Comprehensive Study Guide, ed 7. New York, McGraw-Hill, 2011, (Ch) 249:p 1653-1654.
QUESTION: Which of the following laboratory combinations is most expected in a 75-year-old woman with lung cancer and hyponatremia?
A. Serum osmolarity high, urine osmolarity high, urine sodium low
B. Serum osmolarity high, urine osmolarity low, urine sodium low
C. Serum osmolarity low, urine osmolarity high, urine sodium high
D. Serum osmolarity low, urine osmolarity low, urine sodium low
The syndrome of inappropriate secretion of ADH (SIADH) is defined by the secretion of ADH in the absence of an appropriate physiologic stimulus. Its hallmark is an inappropriately concentrated urine despite the presence of a low serum osmolality and a normal circulating blood volume. Causes of SIADH include central nervous system disorders, pulmonary disease, drugs, stress, pain, and surgery. Therefore, the above patient with a known history of lung cancer and hyponatremia, most likely has SIADH and exhibits the following lab findings: serum osmolarity low, urine osmolarity high, urine sodium high.
Psychogenic polydipsia (D) is a rare cause of euvolemic hyponatremia and is seen in psychiatric patients who consume large amounts of free water (in excess of 1L/hr). This large consumption overwhelms the kidney’s ability to excrete free water. Patients will exhibit low serum osmolarity, low urine osmolarity, and low urine sodium. Diabetes insipidus (B) results in the loss of large amounts of dilute urine from the loss of concentrating ability in the distal nephron. This may be due to a central cause such as the lack of ADH secretion from the pituitary, or a nephrogenic cause, such as the lack of responsiveness to circulating ADH. Laboratory work-up invariably shows high serum osmolarity, low urine osmolarity, and low urine sodium. High serum osmolarity, high urine osmolarity, and low urine sodium (A) rarely occurs.
Gibbs MA, Tayal VS: Electrolyte Disturbances, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 7. St. Louis, Mosby, Inc., 2010, (Ch) 123:p 1615-1632
QUESTION: A 57-year-old man is exposed to radiation as a result of a disaster in a nuclear power plant. It is believed that he sustained significant whole body radiation, although the number of Grays is unknown. He is brought to the ED, his clothes are removed and his body is decontaminated. Two hours after the exposure he begins having nausea and vomiting. Which of the following is the best predictor of survival after radiation exposure?
A. Iodine level at 48 hours
B. Lymphocyte level over 48 hours
C. Monocyte level over 48 hours
D. Platelet levels over 24 hours
This patient is suffering from acute radiation syndrome. The rapid onset of his gastrointestinal symptoms suggests a life-threatening dose of radiation. In acute radiation sickness, the earlier the onset of this prodromal phase, the greater the likely exposure. The most commonly used method of estimating dose exposure and prognosis is the Andrews lymphocyte depletion curves, which examines the level of lymphocyte decline over 48 hours.
Acute radiation syndrome is often accompanied by a hematopoietic syndrome with pancytopenia, infection, and hemorrhage commonly occurring. However, it is the lymphocyte count at 48 hours that best predicts the patient’s course.
Measuring iodine levels (A) has no prognostic value. Monocytes (C) and platelets (D) typically decline over the course of weeks.
Rella J: Radiation, in Flomenbaum NE, Goldfrank LR, Hoffman RS, et al., (eds): Goldfrank’s Toxicologic Emergencies, ed 8. New York, The McGraw-Hill Companies Inc., 2006, (Ch) 128:p 1803-1816
Goans, Ronald E., Holloway, Elizabeth C., Berger, Mary Ellen, and Ricks, Robert C. "Early Dose Assessment Following Severe Radiation Accidents," Health Physics 72(4):1997
QUESTION: Which of the following is the hallmark characteristic of mumps?
A. Cough, coryza, and conjunctivitis
C. Maculopapular rash
D. Nonsuppurative parotid swelling
Mumps is a viral illness characterized by fever, swelling, and tenderness of the salivary glands, with the parotid gland most commonly affected. The disease is seen most commonly in the winter and spring months and is communicable 1 week to 10 days after the onset of parotitis. Nonsuppurative parotid swelling is the hallmark of mumps. The swelling can be unilateral or bilateral and is sometimes associated with trismus. Less commonly, patients experience epididymoorchitis, which also can be unilateral or bilateral, and meningitis. The CSF in these cases usually demonstrates a lymphocyte pleocytosis and low glucose. Rare complications include transverse myelitis, Guillain-Barre syndrome, pancreatitis, myocarditis, and deafness. Treatment is supportive.
Cough, coryza, and conjunctivitis (A) is associated with measles (Rubeola) and precedes the characteristic maculopapular rash by 2 to 4 days. The classic rash of measles is maculopapular (C) and begins on the head and progresses downward over the body over a period of 3 days. Epididymoorchitis (B) is associated with mumps, but much less common than nonsuppurative parotid swelling.
Haile-Mariam T, Polis MA: Viral Illness, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 7. St. Louis, Mosby, Inc., 2010, (Ch) 128:p 1713, 1717-1718
QUESTION: Which of the following is true regarding the condition seen above?
A. Leads to scarring alopecia
B. Primarily due to bacterial infection
C. Requires long term topical treatment with antifungal
D. Usually painless
The image depicts a patient with a kerion. This condition begins as Tinea capitis (scalp ringworm) that undergoes a delayed-type hypersensitivity reaction to the causative fungus. This inflammation causes the initial erythematous, scaly plaque of Tinea capitis to become boggy with inflamed, purulent nodules and plaques. The hair follicle is frequently destroyed by the inflammatory process in a kerion, leading to scarring alopecia. Treatment includes long-term systemic therapy, usually with oral griseofulvin and the addition of an antibiotic to treat any secondary bacterial infection. In addition, oral corticosteroids are administered to treat the severe inflammation.
Tinea capitis is a dermatophyte (B) infection most commonly caused by Trichophyton tonsurans that is transmitted from person to person via fomites, such as a barber’s razor. Treatment with topical agents (C) is inadequate and patients require systemic therapy. The initial infection of Tinea capitis is usually painless (D) with intense pruritus at times. However, with progressive inflammation and the development of a kerion, the lesion becomes painful.
Hardin JM: Cutaneous Conditions, in Knoop KJ, Stack LB, Storrow AB, Thurman RJ (eds): The Atlas of Emergency Medicine, ed 3. New York, The McGraw-Hill Company, 2010, (Ch) 13:p 388-389.
Trovato MJ, Schwartz RA, Janniger CK. Tinea capitis: current concepts in clinical practice. Cutis. Feb 2006;77(2):93-9.
QUESTION: A 55-year-old woman is receiving a blood transfusion due to persistent vaginal bleeding and hemoglobin of 5 mg/dL. While receiving the transfusion, she develops fever, chills, back pain, pain at the site of transfusion, and tachycardia. After stopping the transfusion, which of the following is the most important therapy to administer next?
C. Intravenous hydration
Up to 20% of all transfusions may lead to some type of adverse reaction. Although most of these reactions are minor, some are life threatening. The patient is having an acute intravascular hemolytic reaction. This occurs when the recipient’s antibodies recognize and induce hemolysis of the donor’s red blood cells. In this reaction, most of the transfused cells are destroyed, which may result in activation of the coagulation system and disseminated intravascular coagulation. This type of reaction typically presents with back pain, pain at the site of transfusion, headache, fever, hypotension, dyspnea, tachycardia, chills, bronchospasm, pulmonary edema, bleeding, and development of renal failure. The first step is to stop the transfusion. It is then important to initiate intravenous hydration to maintain diuresis. Vital signs should also be monitored due to the potential for hypotension.
Acetaminophen (A) can be administered to patients who develop an isolated fever during the transfusion. If this occurs, it is important to stop the transfusion and make sure there is not a more severe reaction occurring and the blood bank should be notified. Diphenhydramine (B) can be administered in mild reactions and should be accompanied by cessation of the transfusion and further investigation into a more serious reaction. Solumedrol (D) can be administered in patients with moderate to severe allergic reactions.
Coil CJ, Santen SA: Transfusion Therapy, in Tintinalli JE, Kelen GD, Stapczynski JS (eds): Emergency Medicine, A Comprehensive Study Guide, ed 7. New York, McGraw-Hill, 2011, (Ch) 233:p 1497-1498.
QUESTION: A 36-year-old woman presents to the ED with hemoptysis that began just prior to arrival. She reports generalized fatigue and dark urine over the past 3 months. Her vital signs are within normal limits. Her laboratory studies are notable for a creatinine of 2.3 mg/dL, 3+ blood on urinalysis and a hemoglobin of 9.8 mg/dL. Which of the following is the most likely etiology of this patient’s symptoms?
A. Churg Strauss syndrome
B. Granulomatosis with Polyangiitis
C. Polyarteritis nodosa
D. Systemic sclerosis
This patient has Granulomatosis with Polyangiitis (GPA) (formerly referred to as Wegener’s granulomatosis) as demonstrated by hemoptysis, hematuria, and renal insufficiency. GPA is a multisystem vasculitis with necrotizing granulomas that involve the pulmonary and renal systems. The most common presenting symptoms are hemoptysis and hematuria. The upper and lower airways, as well as the ears, may be involved. Non-specific symptoms such as fatigue and joint pain are often present. Glomerulonephritis with renal insufficiency can occur. Skin findings include cutaneous nodules and palpable purpura. Cardiac involvement is rare but potentially fatal. Treatment involves stabilizing the patient and corticosteroids as well as immunosuppressant agents such as cyclophosphamide in conjunction with a specialist.
Churg Strauss syndrome (A) is a multisystem vasculitis that presents with bronchospasm (progressing to possible airway obstruction), as well as sinusitis. Peripheral eosinophillia is often present. Cardiac and gastrointestinal symptoms may also occur; however, hemoptysis and hematuria are less common in Churg Strauss than in granulomatosis with polyangiitis. Polyarteritis nodosa (C) is also a multisystem vasculitis. While its presentation generally involves non-specific systemic complaints, organ-specific complications such as renal failure, gastrointestinal bleeding, cardiac ischemia, and stroke may also be seen. Pulmonary involvement is relatively uncommon. Systemic sclerosis (D) is characterized by excessive collagen deposition with vascular and endothelial dysfunction. Patients often present with thickened skin and ischemic digits along with gastrointestinal symptoms, possibly due to stricture formation. The renal and pulmonary systems can also be involved but the patient in this scenario does not have any other symptoms consistent with systemic sclerosis.
Morabito GC, Tartaglino: Emergencies in Systemic Rheumatic Diseases, in Tintinalli JE, Stapczynski JS, Ma OJ, et al (eds): Tintinalli’s Emergency Medicine, ed 7. New York, The McGraw-Hill Companies Inc., 2011, (Ch) 279:p 1911-1920
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