is not helpful in diagnosing a rib fracture. A thoracentesis (e), whether diag-
nostic or therapeutic, is indicated only in patients with pleural effusions.
66.The answer is d.(Rosen, pp 1557-1564.)The patient has normal vitals,
a normal chest radiograph, and is stable. In fact, her symptoms self-resolve
with time and without intervention. Only with this information can one be
comfortable with making the diagnosis of an anxiety attackas the precip-
itant to the patient’s symptoms. A history of a stressor may be helpful, but
it is important to note that these symptoms are not under the voluntary
control of the patient, and often patients may not even be able to identify a
specific stressor. It is important to remember that the diagnosis of anxiety
in the ED is a diagnosis of exclusion. Her extremity symptoms are typical
ofcarpal-pedal spasmseen with tetany, a result of a transient decrease in
calcium serum levels secondary to a respiratory alkalosis.
(a)A pneumothorax and hemopneumothorax (b)are generally seen
with trauma and typically present with decreased breath sounds and abnor-
mal oxygen saturation. A pleural effusion (c)has many etiologies and usu-
ally presents with decreased breath sounds at the point of effusion. Asthma
(e)generally manifests itself with wheezing on examination.
67.The answer is c.(Rosen, pp 938-956.)Corticosteroidshave been
shown to improve asthma symptoms in subsequent days after an exacerbation
and prevent acute recurrences in patients who are deemed suitable to be dis-
charged from the ED. An acceptable dosage is 40- to 60-mg prednisone daily
for 3 to 10 days after the initial event. Inhaled steroids may also be an alterna-
tive to prevent relapses in more intractable cases, and should be used daily
with the guidance of the patient’s primary-care provider. Spacers are available
to ensure adequate delivery of the medications deep into the alveoli.
Cromolyn (d)acts as a mast cell stabilizer and is used primarily in the
management of allergic rhinitis. Ipratropium (e)is an anticholinergic med-
ication that is used in the management of COPD. Although it is usually
administered in the acute care of asthma, it is not indicated for asthma main-
tenance. Adequate amounts of magnesium (a)should be obtained in the
patient’s diet. EpiPens (b)are only indicated for those patients who suffer
severe allergic reactions and are not given on an outpatient basis in patients
with asthma.
68.The answer is e.(Rosen, pp 2560-2568.)Attention to airway and
breathing is of particular importance in opioid intoxication,as indicated
Shortness of Breath Answers 73