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A 45-year-old woman presents to the emergency department with a 2-day history of leg pain and swelling following what she describes as "a small scratch" from gardening. On examination, there is mild erythema and tenderness over the anterior shin with minimal induration. Vital signs are BP, 135/82; P, 88; T, 37.9°C (100.2°F). Point-of-care ultrasound of the affected area is performed. Which of the following ultrasound findings is most concerning and requires immediate surgical consultation? 👍 A. Highly echogenic areas with posterior acoustic shadowing in the fascial planes B. Hypoechoic strands between subcutaneous fat tissue C. Hyperechoic linear structure with multiple parallel reverberation artifacts D. Discrete anechoic regions with posterior acoustic enhancement in subcutaneous tissues E. Noncompressible hypoechoic tubular structure in the deep posterior compartment This describes gas shadowing, which strongly suggests necrotizing fasciitis. The highly echogenic (bright) areas represent gas produced by bacteria, and the posterior acoustic shadowing occurs because the gas prevents sound transmission through deeper tissues. This finding, particularly in the fascial planes, indicates tissue necrosis that requires immediate surgical consultation for emergency debridement.

A 42-year-old woman presents with progressive dyspnea. Physical examination shows decreased breath sounds and dullness to percussion over the right lower lung field. Chest x-ray shows a large right-sided pleural effusion that occupies approximately 60% of the hemithorax. The patient is hemodynamically stable. Therapeutic thoracentesis with removal of 1.6 L of straw-colored fluid is performed. Shortly after the procedure, the patient develops a cough and chest discomfort, and oxygen saturation drops to 88% on room air. What is the most likely complication? A. Pneumothorax 👍 B. Pulmonary edema C. Hemothorax D. Pleuritis E. Pleural empyema Reexpansion pulmonary edema is a recognized complication of therapeutic thoracentesis that occurs after rapid reexpansion of lung tissue. Risk factors include large volume removal (> 1.5 L). The classic presentation includes cough, chest discomfort, and hypoxia that develop during or immediately after the procedure.

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🧩 Medical Mnemonics Pemphigus vulgaris — 6🅿️ 🅟ainful → oral erosions 🅟eels → flaccid blisters rupture easily 🅟ositive Nikolsky → skin slips off 🅟rotein (Desmoglein) → desmosomes attacked 🅟artial layer → intraepidermal split 🅟rime age → middle-aged adults (40–60) ▫▪▫▪▫▪▫▪▫▪▫ Bullous pemphigoid — 6🅱️ 🅑ullae → tense blisters 🅑ig → firm, intact 🅑asement → hemidesmosomes 🅑ody itch → pruritic 🅑elow → subepidermal split 🅑eyond Prime → elderly (>65) #dermatology 〰〰〰〰〰〰〰〰〰〰〰 ©Medical Mnemonics

A 52-year-old man with septic shock is receiving norepinephrine through a peripheral IV in his left forearm. The nurse reports that the patient complained of burning pain at the IV site 30 minutes ago, but the infusion was continued. On examination, there is a 4 cm area of erythema and induration around the IV site with overlying skin blanching. The IV is discontinued and the catheter removed. What is the most appropriate immediate intervention? A. Consult plastic surgery for immediate evaluation B. Administer hyaluronidase subcutaneously 👍 C. Inject phentolamine around the extravasation site D. Mark the boundaries and elevate the limb E. Apply cold compresses to the affected area Correct -- For vasopressor extravasation, including norepinephrine, phentolamine is the preferred reversal agent and should be injected around the extravasation site as the immediate intervention. Subsequent management includes topical nitroglycerin application and the use of warming compresses.

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A 78-year-old patient with dementia and a percutaneous endoscopic gastrostomy (PEG) tube placed 8 weeks ago for dysphagia presents after the tube was accidentally pulled out 3 hours ago during routine care. The patient appears comfortable with normal vital signs. Physical examination shows a patent stoma site without erythema, induration, or discharge. What is the most appropriate next step in management? A. Start empiric antibiotics and monitor for peritonitis B. Consult gastroenterology for endoscopic tube replacement C. Apply sterile dressing and schedule outpatient replacement 👍D. Insert a replacement gastrostomy tube or Foley catheter E. Obtain abdominal CT with contrast to assess for perforation For late dislodgement (> 4 weeks after placement), bedside gastrostomy tube replacement is safe and appropriate. A replacement tube or Foley catheter should be inserted immediately to prevent tract closure, which occurs within hours of tube removal.

68-year-old patient with congestive heart failure (ejection fraction 30%) and moderate COPD presents to the emergency department with anterior shoulder dislocation after a fall. Vital signs are BP, 100/65; P, 92; R, 22; oxygen saturation, 90% on room air. The patient appears uncomfortable and requires immediate closed reduction. The patient has been NPO for 6 hours. Which sedative agent is most appropriate for this procedure? A. Ketamine B. Dexmedetomidine C. Midazolam 👍 D. Etomidate E. Propofol

A 28-year-old man presents with altered mental status and vomiting after falling from a ladder. Vital signs are BP, 100/65; P, 55. His Glasgow Coma Scale score is 8. Neurological examination reveals anisocoria with sluggish pupillary responses. He requires emergency intubation for airway protection. Which induction agent is most appropriate? A. Fentanyl B. Propofol C. Ketamine 👍 D. Etomidate E. Midazolam Correct Answer Is D Correct – Etomidate is the preferred induction agent for patients with suspected increased ICP because it can reduce ICP while having minimal effect on blood pressure.

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