546 Emergency Medicine
Previous attempts/psychiatric care 1
Excessive alcohol or drug use 1
Rational thinking loss 2
Separated, divorced, or widowed 1
Organized or serious attempt 2
No social support 1
Stated future attempt 2498.The answer is a.(Rosen, pp 1549-1583.)The physical examination
in this patient reveals hand abrasions, indicative of self-purging. Her general
appearance suggests either inadequate food intake or excessive calorie burning.
Bulimicsgenerally consume an adequate amount of food, albeit low-calorie,
but purge their intake with the goal of weight loss. Other eating disorders,
such as anorexia nervosa, can take the form of starvation, diuretic or laxative
use, or excessive exercise. These patients generally suffer from a false visual-
izationof their body, believing that their physical form weighs more than
what it does in reality. Social pressures, history of abuse or violence, and
other eatingdisorders may factor in to this patient’s presentation.
Gastroenteritis (b)is unlikely given the lack of history or symptoms.
Suicidality(e)should be examined in all patients, as their actions may represent
a form of occult or hidden self-harm. This patient does not exhibit signs of
malingering(c)or factitious disorder (d).
499.The answer is c.(Rosen, pp 1549-1583.)Tricyclic antidepressants
(TCAs) are responsible for more drug-related deaths than any other pre-
scription medication. This ECG shows QRS interval prolongation, a common
finding with this medication. The mechanism of toxicity is multifold and
includes blocking the reuptake of dopamine, serotonin, and norepinephrine.
It also binds to the γ-aminobutyric acid (GABA) receptor, thereby lowering
seizure threshold. Sodium-channel blockade produces the widened QRS
interval. There are also anticholinergic and antihistamine effects. Sodium
bicarbonate is a first-line intervention for dysrhythmias, acting as alkalizing
binder for the acidic TCA. This treatment has been shown to improve con-
duction and contractility with the goal of preserving a narrow QRS.
Benzodiazepines(a), ethanol (b), insulin (d), and valproic acid (e)have
not been shown to exhibit any ECG abnormalities.
500.The answer is c.(Rosen, pp 1549-1583.)This patient recently gave birth
and presents with symptoms of hopelessness and guilt in the subsequent weeks,