APEA Acute Care and Urgent Presentations 2 — Questions and Answers
Question 1: A 19-year-old male presents with right testicular pain and swelling of 3 hours duration. Cremasteric reflex is absent. The immediate next step is:
- Prescribe antibiotics for suspected epididymo-orchitis and schedule follow-up in 2 weeks
- Emergent urology consultation for suspected testicular torsion — surgical detorsion is required within 4 to 6 hours to preserve testicular viability (Correct answer)
- Order a scrotal ultrasound and wait for results before any intervention
- Apply ice and reassess in the emergency department
Correct answer: Emergent urology consultation for suspected testicular torsion — surgical detorsion is required within 4 to 6 hours to preserve testicular viability
Absent cremasteric reflex with acute onset testicular pain is testicular torsion until proven otherwise. Surgical detorsion within 4-6 hours preserves testicular viability in more than 95% of cases.
Testicular torsion is most common in adolescents but occurs at any age. Classic presentation: sudden severe unilateral scrotal pain, swelling, absent cremasteric reflex, and high-riding testis. Color Doppler ultrasound can confirm absent blood flow but should never delay surgical consultation if clinical suspicion is high. Viability: below 6 hours approximately 96%; 6-12 hours approximately 70%; above 24 hours below 10%.
Question 2: A 65-year-old patient on warfarin presents with sudden onset severe headache, left-sided weakness, and confusion. CT head without contrast shows a hyperdense region in the right basal ganglia. The most likely diagnosis and immediate management is:
- Ischemic stroke — administer tPA immediately
- Intracerebral hemorrhage — reverse anticoagulation immediately with 4-factor PCC or FFP, and involve neurosurgery (Correct answer)
- Hypertensive urgency — reduce blood pressure with oral labetalol
- Migraine with aura — provide analgesics and discharge
Correct answer: Intracerebral hemorrhage — reverse anticoagulation immediately with 4-factor PCC or FFP, and involve neurosurgery
Hyperdense region on non-contrast CT in an anticoagulated patient with acute focal deficits indicates intracerebral hemorrhage. Emergent anticoagulation reversal with 4-factor prothrombin complex concentrate minimizes hematoma expansion.
Intracerebral hemorrhage in an anticoagulated patient requires immediate reversal: warfarin is reversed with vitamin K 10mg IV plus 4-factor PCC (preferred over FFP for speed of INR correction); NOACs are reversed with specific agents (dabigatran with idarucizumab; rivaroxaban or apixaban with andexanet alfa or 4-factor PCC). tPA is absolutely contraindicated in hemorrhagic stroke. Blood pressure target: SBP below 140 with IV labetalol or nicardipine.
Question 3: A 55-year-old patient with known COPD presents in acute respiratory distress with RR 32, SpO2 82%, pursed-lip breathing, and use of accessory muscles. Initial management priority is:
- Order a chest CT scan before initiating treatment
- Supplemental oxygen titrated to SpO2 88 to 92%, short-acting bronchodilators (albuterol plus ipratropium), and systemic corticosteroids (Correct answer)
- Immediately intubate without trialing non-invasive interventions
- Administer IV diuretics for suspected pulmonary edema
Correct answer: Supplemental oxygen titrated to SpO2 88 to 92%, short-acting bronchodilators (albuterol plus ipratropium), and systemic corticosteroids
Acute COPD exacerbation management: controlled oxygen targeting SpO2 88-92% (avoid hyperoxia), inhaled bronchodilators (SABA plus SAMA), and systemic corticosteroids. NIV (BiPAP) for persisting hypercapnia before considering intubation.
COPD exacerbation management per GOLD guidelines: controlled O2 targeting SpO2 88-92% (high-flow O2 can suppress hypoxic respiratory drive and worsen hypercapnia); albuterol via nebulizer; ipratropium nebulizer; prednisone 40mg PO for 5 days; antibiotics if Anthonisen criteria are met (purulent sputum, increased dyspnea, increased sputum volume); NIV (BiPAP) for pH below 7.35 with elevated PaCO2; intubation if NIV fails.
Question 4: A 40-year-old female presents with her 5th urinary tract infection in 12 months. Urine cultures consistently grow E. coli. The most appropriate management to prevent recurrent UTIs is:
- Increase fluid intake alone without further evaluation
- Evaluate for structural urinary abnormalities; consider prophylactic antibiotics (TMP-SMX or nitrofurantoin), post-coital antibiotics if coitally related, or patient-initiated therapy (Correct answer)
- Long-term high-dose ciprofloxacin
- Recommend cranberry juice as the sole preventive strategy
Correct answer: Evaluate for structural urinary abnormalities; consider prophylactic antibiotics (TMP-SMX or nitrofurantoin), post-coital antibiotics if coitally related, or patient-initiated therapy
Recurrent UTIs (2 or more in 6 months or 3 or more in 12 months) warrant evaluation for predisposing factors and management with evidence-based prophylactic strategies.
Recurrent UTI management options: (1) Continuous prophylaxis: TMP-SMX 40/200mg or nitrofurantoin 50-100mg at bedtime for 6-12 months; (2) Post-coital prophylaxis: single dose after intercourse; (3) Patient-initiated therapy: self-start antibiotics at first symptoms. Evaluation should assess for risk factors including DM, urinary retention, structural abnormalities, and sexual activity patterns. Cranberry products have modest evidence but do not replace antibiotics.
Question 5: A 10-year-old child presents with high fever, severe odynophagia, uvular deviation, drooling, and a muffled 'hot potato' voice. This presentation is most concerning for:
- Streptococcal pharyngitis requiring amoxicillin
- Peritonsillar abscess (PTA) requiring drainage and IV antibiotics (Correct answer)
- Viral tonsillitis requiring supportive care
- Epiglottitis requiring immediate airway assessment
Correct answer: Peritonsillar abscess (PTA) requiring drainage and IV antibiotics
Peritonsillar abscess presents with fever, severe throat pain, uvular deviation away from the abscess, drooling, and muffled hot potato voice due to peritonsillar pus collection. Treatment: needle aspiration or incision and drainage plus IV antibiotics.
PTA is the most common deep neck infection. Signs include unilateral peritonsillar bulge with uvular deviation to the contralateral side, trismus, drooling, hot potato voice, and fever. Treatment is needle aspiration (preferred first-line) or I&D plus penicillin G IV or amoxicillin-clavulanate. Differentiate from epiglottitis which is more acutely progressive and does not cause uvular deviation.
Question 6: A 78-year-old nursing home patient presents with fever, altered mental status, and decreased urine output. Vital signs: BP 88/60, HR 118, RR 26, Temp 38.9°C. Suspected source is urinary. Per Sepsis-3 criteria, which finding most strongly suggests septic shock?
- Fever alone in an elderly patient
- Hypotension requiring vasopressors to maintain MAP of 65 mmHg or higher with elevated lactate above 2 mmol/L despite adequate fluid resuscitation (Correct answer)
- Altered mental status without other vital sign changes
- Elevated WBC above 12,000
Correct answer: Hypotension requiring vasopressors to maintain MAP of 65 mmHg or higher with elevated lactate above 2 mmol/L despite adequate fluid resuscitation
Sepsis-3 defines septic shock as sepsis with vasopressor requirement to maintain MAP of 65 mmHg or higher and serum lactate above 2 mmol/L despite adequate fluid resuscitation.
Sepsis-3 definitions: Sepsis is life-threatening organ dysfunction (SOFA score increase of 2 or more) caused by dysregulated host response to infection. Septic shock is a subset with vasopressor requirement for MAP of 65 mmHg or higher and lactate above 2 mmol/L despite adequate fluid resuscitation. In-hospital mortality for septic shock exceeds 40%. Hour-1 bundle includes lactate measurement, blood cultures before antibiotics, broad-spectrum antibiotics within 1 hour, 30 mL/kg IV crystalloid for hypotension, and vasopressors (norepinephrine preferred) if MAP below 65.
APEA Acute Care and Urgent Presentations 2
A 19-year-old male presents with right testicular pain and swelling of 3 hours duration.
Cremasteric reflex is absent.
The immediate next step is: