BOARD PREP
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# ???
mcc of UTI in young F? #2? what is honeymoon cystitis?
#1 is E. Coli; *#2 = staph saprophyticus* HC: w/in 24 hrs of sex --> UTI
DERM
#12
OPHTHO
#16
ADMIN
#17
TOX
#9
non face/scalp lac > 12 hrs and dirty and contaminated - NBS
'delayed primary closure': return in 3-5 days for repair. wound cleaned & left open *until risk of infxn lowered* to when it can be repaired (ie 3-5 days later) ideal for dirty/contaminated wound
SBP: how to make Dx? mcc? Tx?
(+) fluid Cx w/ *> 250 PMN's; E. coli; rocephin* (or cefotaxime or cefepime)
Schizophrenia: (+) & (-) Sx
(+): delusions, hallucinations, disorg speech/behavior -Tx-able with atypical anti-psychotics (block DA-R) (-): flat affect, lack of speech -often refractory to Tx
retropharyngeal abscess XR 6
*"6 at 2, AND 22 at 6"* 6 mm soft tissue swelling @ C2 22 mm soft tissue swelling @ C6 = "widening of pre-vertebral soft tissue"
top 4 post-MI complications: cause of death & timeline
*1st hr*: VFib *1st wk*: vent free wall rupture --> tamponade *w/in 2 wks*: papillary mm. rupture --> acute MR w/in *2-8 wks: Dressler syndrome*
NMJ d/o classification (8) - ABCD
*A*Ch (2): MG, LEMS *B*ugs (2): tick, botulism (technically both ACh-related) Periodi*C/C*yclic: hypoK, thyrotoxic *D*emyelinating AI (2): MS, GBS
emergent dialysis indications
*AEIOU*: *A*cidosis, *E-* abnormalities, *I*ngestion/tox, *O*verload fluid, *U*remia
miscarriage types (5) - name, cp, os open or closed
*ANY POC's PASSED YET?:* 1) COMPLETE: cramping with *prior passing of POC's*, now fine w/ US showing *empty uterus; os closed* (miscarriage has already happened, it's COMPLETE) 2) INCOMPLETE: bleeding w/ intense pain/cramps & *active passage of POC's; os open* (actively miscarrying, process is yet INCOMPLETE) - *MC ones; DIFFICULT to Dx:* 3) THREATENED: vag bleed/clots w/ pain; *os CLOSED* (miscarriage is a THREAT but not yet for sure) 4) INEVITABLE: vag bleed/clots w/ pain; *os OPEN* (miscarriage is INEVITABLE but no POC yet) - 5) SEPTIC: poly infxn --> fever, ab pain, vag bld + *vag d/c w/ septic VS*; forget os - Tx w/ *IV Abx + D&C*
how to tell if neonate has TP FOBT
*APT TEST*: enzymatic sol'n added to neonate stool. if mom blood is present = TURNS BROWN. *if it stays red*, that's legit fetal blood. -swallowed maternal blood = FP FOBT
what are you really asking yourself with Sgarbossa criteria
*ASK YOURSELF*: 1) any (+) concordance at all in any lead? (ie any ST segment that follows the QRS lead) = 5 pts 2) any excessive discordance (ie STE > 5 mm?) = 2 pts 3) any (-) concordance (ie both down) in V1-V3? (this one *confusing: any STD in V1-V3?*) = 3 pts
AVNRT vs AVRT
*AVNRT* (AV Nodal Re-entrant Tachycardia): abnormal circuit *w/in AVN itself*; ex: PSVT *AVRT* (Atrio-Ventricular Re-entrant Tachycardia): abnormal circuit involves AVN but not w/in it- thru an *accessory pathway (BoK) b/w A & V*; cause of pre-excitation syndromes (*WPW*); *ortho vs antidromic*
BREECH think this
*B*REECH = *B*UTTOCKS PRESENTING or BR*EE*CH = F*EET* PRESENTING
meningitis PE signs
*B*rudzinski: *B*end/flex neck, reflexive hip flexion *K*ernig: hip flex to 90º, *K*nee cannot straighten
aspirin has same antidote as
*BARBITURATES*: urinary alkalinization + HD (I *S*TUM*B*LED)
these Rx can mask sx of hypoglycemia
*BB* (hypoglycemic unawareness 2/2 fact that BB blunt β-fx of adrenalin --> do not experience typical adrenergic warning Sx ie no tremor, palpitations)
fundo findings for CRAO vs CRVO
*BCR* - think 1 focal issue in turn causing diffuse changes (focal = cherry red SPOT, retinal HMRG) CRAO = Boxcar, Cherry Red, Retina pale CRVO = Blood & thunder, Cottonwool, Retinal hmrg
amiodarone A/E
*C*heck *P*FTs, *L*FTs and *T*FT's C: Corneal deposits Pulm: Fibrosis Liver: toxicity Thyroid: inflm
indications for imaging in suspected overdoses?
*CHIPES*: radio-opaque pills seen on XR *Chloral hydrate, *H*eavy metals, *I*ron, *P*otassium, *E*nteric-coated tablets, *S*low-release forms
pre-eclamptic Pt seizes - think? -NBS -be careful for
*ECLAMPSIA* -Tx - loading dose of *Mg 4-6 g* + delivery -watch for *hyperMg (> 3.5): decr DTR's & resp depression* 2/2 diaphragm paralysis - needs IVF, Lasix & *calcium gluconate* 10% 15-30mL IV over 5min
post-menopausal woman w/ vaginal bleeding - NBS
*EMB/US* = Endometrial biopsy & US to r.o *endometrial* cancer
metabolizes to oxalic acid -found in -expected gaps -expected Sx from toxicity -Tx
*ETHYLENE GLYCOL* -in: *antifreeze, car coolants, brake fluid* (think *CAR*) -(+) AG, (+) OG -Sx: *ARF, kidney stones, hypoCa* 2/2 *calcium oxalate crystals* -Tx: *fomepizole, EtOH* (both w/ incr affinity for Alcohol Dehydrogenase > methanol. IV EtOH not common but poss Tx option); *HD* (I-STUMBL*E*D)
pseudogout vs gout: crystals, mc jt, XR, acute vs chronic Tx
*Gt*: monosodium urate Cx; great toe; XR neg -Tx: acute NSAID, *Colchicine*, CS; (*AC*) chronic: *allopurinol*, probenecid (*CA*) *PG*: Ca pyrophosphate Cx; knee; XR (*pic*: jt calcified) -Tx: acute NSAID, *Colchicine*, CS; *no* chronic (PG is a *C*li*PP*er = PG = *C*alcium *P*yro*P*hosphate)
neck trauma: HARD signs of vascular injury that indicate emergent surg
*HARD B*ruit htn/Hematemesis/Hemoptysis/Hmrg (pulsatile) Arterial bleed (ie pulsatile) Rapidly expanding hematoma Deficits - neuro or pulse Bruit or Thrill use for ANY trauma really
Pre-eclampsia associated Dz so much ck these
*HELLP* syndrome: *H*emolysis, *E*levated *L*iver enzymes, *L*ow *P*LT - check CBC & CMP
CIWA score pnemonic
*HOT SANTA VA* HA 0-7, Orientation *0-4*, Tremor 0-7 Sweating 0-7 Anxiety 0-7 Nausea (and Vomiting) 0-7 Tactile Hallucinations 0-7 Auditory Hallucinations 0-7 Visual Hallucinations 0-7, Agitation 0-7
5 y/o w/ viral URI last week now with *new rash on legs/buttocks that you can feel* w/ non-specific jt paints, belly pain - think -aka -pp -other sx -timeline -Dx -Tx -comp
*HSP* -aka Henoch-Schönlein purpura, anaphylactoid purpura, or purpura rheumatic -pp: *IgA* vasculitis* -S/S: hematuria, arthralgia, ab pain -time: 4-6 y/o, resolves after *4 wks* (self-limited) -Dx: *UA*: hematuria w/ RBC casts/proteinuria -Tx: supp (NSAID, IVF) but *if hematuria/renal Dz = admit & CS* but if not that, *most can be Tx'd as O/P* -comp: *Ileoileal intusssuception* (as opposed to mc ileocolic form); 33% recurrence rate
HSP not to be confused with
*HUS* - think ART, a/w TTP HSP - hematuria (IgA nephropathy), skin (purpuric rash on buttocks), pain in GI (intussusception) + pain in jts
major systemic complication of EHEC (E coli O157:H7) - think -triad -cp -comp -AVOID
*HUS*: Hemolytic Uremic Syndrome -*ART*: Anemia, Renal failure, Thrombocytopenia -cp: 5-10d after diarrhea from E Coli, now sx of *ART* (ab pain, vomiting, bloody stools) -comp: *TTP-HUS* (thrombotic thrombocytopenic purpura (*FAT RN* = fever + neuro Sx) -*AVOID Abx!* (worsen outcomes bc promotes toxin release)
#1 reason for admission in 1st trimester -def'n -timeline -Tx
*HYPEREMSIS GRAVIDARUM* -intractable N/V w/ *some degree of wt. loss* -Sx peak @ 9-10 wks, resolve by 16-18 wks -Tx: grade *A: vit B6 + doxylamine (diclegis); B: reglan*; C: zofran, promethazine (Phenergan)
e- abnormality a/w hepatic encephalopathy
*Hypokalemia*: increases renal ammonia production despite causing metabolic alkalosis
Dialyzable drugs
*I STUMBLED*: *I*sopropyl etoh, *I*ron, *I*NH A*S*A, *T*heophylline, *U*remia, *M*ethanol (if fomepizole doesn't work), *B*arbiturates, *L*ithium, * E*tOH, *E*thylene Glycol (if fomepizole fails), *D*epkaote (valproic acid)
BP MGMT: ischemic vs hemorrhagic CVA
*ISCHEMIC* - reduce only if: -*tPA* candidate (bc hi BP + lytic is too dangerous) - target is *< 185/110* -or if *SBP > 220 or DBP > 120*: decr *by 25% in 24 hrs* (via nicardipine or labetalol) *HEMHORRAGIC*: target *SBP to 140-160*
sore throat, fatigue, cervical LN & splenomegaly - think? -how to diff from strep -transmission -mcc -Abx leads to? -dispo
*Infectious Mono* -in strep, there's no *POSTERIOR CERVICAL LN* (like there is in mono) -via saliva hence "kissing Dz" -mcc: *EBV (90%)*; others: CMV, HIV, HepB, toxo -amox --> *RASH* (not Rx allergy) -dispo: d/c OK *BUT refrain from contact sports 3 wks* & rpt AB U/S to r/o splenomegaly (risk for rupture)
diaphragm injury mc on which side?
*L side* as R side protected by liver (maybe not true)
SCFE often confused with -problem -clin pres (differed from SCFE) -best imaging
*LCP*: Legg-Calve-Perthes Dz -avascular necrosis of femoral head -*4-6 y/o* with limp -XR neg so get *MRI or bone scan*
chronic limb/bone pain on opioids you confused for seeking behavior - make sure to check this -cp -route of exposure -t-1/2 -Tx
*Lead* toxicity -vague Sx: ab pain, const, irritability, anemia, *wrist/foot drop*, -route: GI in kids; Resp: in adults -short half life in blood but *t-1/2 decades in bone* -Tx: Lead gets L*(ED*TA) *or succimer*
main comp from PTA -pp -cp -mcc
*Lemierre's Syndrome* -pp: infxn spreads from abscess to *internal jugular v. --> thrombosis, septic emboli* -cp: young healthy adult w/ fever, *lateral neck pain & resp distress* -mcc: *Fusobacterium necrophorum*
metabolizes to formic acid -found in -expected gaps -expected Sx from toxicity -Tx
*METHANOL* -in: *paint thinners, window washing fluid* -(+) AG, (+) OG -Sx: *blindness* 2/2 optic disc hypermia -Tx: *fomepizole, EtOH* (both w/ incr affinity for Alcohol Dehydrogenase > methanol. IV EtOH not common but poss Tx option); *HD* (I-STU*M*BLED)
mc form of intracranial neoplasm sigmoid volvulus mc seen in what co-morbidity? Dx/Tx?
*METS* (usu from lung) > 1º SV in chronic constipation; sigmoidoscopy Dx & Tx!
neck pain + neuro Sx (LUE paresthesia) in PEDS Pt after MVA. XR neg. CT neg - NBS? why? mc loc?
*MRI* to r/o *SCIWORA* (Spinal Cord Injury With Out Radiographic Abnormality); think *C-spine* rmr mc in kids bc there is relative laxity in ligaments
painless rectal bleeding in otherwise well appearing infant - think -cp variability -can present as -rule to rmr
*Meckel's Diverticulum* -cp: can be intermittent, can be severe req transfusion -~ to SBO -rule of *TWO's* (5): in 2% of gen pop, only 2% get Sx, loc w/in 2 feet prox to i-c valve, 2 x 2 cm (length x width), if Sx felt half are at age 2
BI Dx for Mono -pro vs con -other labs
*Monospot test (Heterophile Ab test)* -PRO: 100% SP, stays (+) for *1 yr*; CON: poor SN, kids dont produce this Ab so always (-) -labs: 50% lymphocytes (& *10% atypical lymphocytes*)
ETT Meds
*NAVEL*: Naloxone, Atropine, *Valium* (no longer rec), Epi, Lido
what needs to be more emergently removed: needle in esophagus vs button battery in stomach
*NEEDLE*: anything sharp is dangerous -BB if singular is OK if no Sx - can be Tx'd expectantly
pulsus paradoxys physio
*NL*: insp --> decr intra-thoracic P --> incr blood flow to R heart --> incr P transmitted to RV wall (there's more blood in lungs during insp so small drop in BP expected) *PP*: incr in R heart flow now cannot transmit P to RV wall (bc of pericardial fluid) so instead *bounces back to IV septum --> decr LV filling --> drop in SV/SBP*
what to avoid in children with viral illness in terms of Tx -till when -cp
*NO ASA in VIRAL ILLNES = REYE SYNDROME* -till age 12, some say *18* -cp: rash, vomiting, *liver failure* (cirrhosis, lethargy, encephalopathy)
biggest c/i for suspected previa
*NO PELVIC EXAM!!!* any Pt w/ bleeding after 24 wks needs US to r/o previa before a pelvic exam is done
metformin biggest A/E -biggest rFx contributing to this -Tx
*NOT* hypoglycemia *BUT LACTIC ACIDOSIS* (w/ subsequent *HYPERKALEMIA* (rmr K follows H) -rFx: decr renal clearance -def Tx = dialysis
diver descends quickly --> motor impairment, then LOC - think -depths to watch out for -Sx -Tx -comp
*Nitrogen Narcosis* -*> 100 ft* -Sx: feels like you're on anesthesia (impaired motor control) *w/ LOC* -Tx: *rapid ascent* -comp: impaired judgment --> drowning fatalities
Hypothermia EKG; mc in what leads T/F: height of Cx wave correlates with degree of hypothermia T/F: Cx waves are pathognomonic for hypothermia
*Osborne* or J wave (positive deflections); seen mc in precordial leads -T: roughly correlates w/ degree of hypothermia -F: seen in other conditions (ICH, hyperCa)
1LTx of TTP-HUS
*PLASMAPHERESIS*: do DAILY *until PLT's normalize*
ELBOW: which fat pad is bad -indicates?
*POSTERIOR* = JOINT EFFUSION = *BAD* = POOR PROG -think radial head fx for adults think supracondylar fx for kids
mcc of Upper GIB mcc of Lower GIB
*PUD* for upper diverticulosis for lower
MC deep facial infxn in adults -cp -mcc -Dx -Tx
*Peritonsillar abscess (PTA)*: deep infxn *in space b/w* soft palate and tonsil -cp: *teen/young healthy adult* w/ fever, sore throat, *TRISMUS, HOT POTATO VOICE, DEVIATED UVULA* -mcc: *polymicrobial* -Dx: CT not nec but if needed - CT w/ con -Tx: I&D, Abx
phimosis paraphimosis -problem -NBS/prog -comp -Tx
*Phimosis*: -inability to retract foreskin from TOP -rarely emergent; comp: retention; Tx: circumcision prn *Paraphimosis*: -retracted foreskin that cannot be moved back -surg emergency; comp: necrosis -Tx: ice, manual rdxn or incision
which vessel is preferred site of insertion for pacemaker
*R IJV* or L sublacvian --> tip in RV
in tamponade and PE on echo, what chamber to focus on
*RV* tamponade: *diastolic collapse of RV* PE: wall of RV won't contract but apex is spared
mc injured heart chamber in penetrating trauma
*RV/RA* 2/2 their anterior location
urine dipstick + for blood but not on microscopic exam - think -Dx -labs -comp -Tx
*Rhabdo* -CPK > 5x the upper limit -metacid, hyperK/P/Uric acid + hypoCa (same as *tumor lysis syndrome* = WT*PUCK*) -@ risk for *heme-induced ARF* -Tx: IVF
SALTER HARRIS Fx
*S*lip: @ physis *A*way (not above bc flipped bone *L*ower *T*hru *E*verything c*R*ush/*R*ammed
mcc of AVF infection - think? Tx?
*S. aureus* #1 (staph epidermidis #2); Tx: vanco
obese young teen (14-16 y/o) with hip pain - think -u/l or b/l? -best imaging
*SCFE*: slipped capital femoral epiphysis -BOTH: can be *b/l* -XR: *frog leg* fat boys that eat Jiffy get SCFE
invasive diarrhea DDX
*SEC-SEY*: Salmonella, E coli, Cambylobacter Shigella, E. histolytica, Yersinia entercolitis *Diarrhea is SEXY*
MC injured organ in GSW
*SI* > colon > liver GUN --> GUT
how long can pre-eclampsia last for
*SIX WEEKS post-partum*
Cholinergic toxicity Sx -3 ways to die from this -caused by -Tx/antidote
*SLUDGE-M*: Salivation, Lacrimation, Urination, Defecation/Diaphoresis, Gastric upset, Emesis, Miosis (pupillary constriction) -3 killer B's: *B*radycardia, *B*ronchorrhea, *B*ronchoconstriction -caused by *organophosphates (insecticides)* -Tx: *ATROPINE* + *2-PAM (PRALIDOXIME)* Chol = GB so think *SLUDGE*
biostats reminder: SN vs SP vs PPV vs NPV
*SN/SP - start with Pt/Dz* -HI SN - *if Dz is present*, test is actually (+) ie TP: D-d -LO SN - *if Dz is present*, test will be *FN* *if Low SeNsitivity, think False Negativity* *SN* so think *S*cree*N* why *SNOUT*? bc HI SN decr FN, so 100% SN = no FN, so everyone who is neg is actually neg. or if hi SN, so 100% of TP, there are NO FP so only the (+) are sick -HI SP - *if Dz is absent*, test will correctly be (-) ie TN -LO SP - *if Dz is absent*, test may be *FP* *if Low Specificity, think False Positivity* *SPIN* to rule in PPV/NPV: start w/ Test PPV - if test is (+), Patient actually has Dz NPV - if test is (-), Patient actually does not have Dz
(+) NIKOLSY w/o MM involvement
*SSSS* w/ MM: SJS/TEN, Pemphigus Vulgaris (toxic shock syndrome has mucosal involvement but (-) Nikolsky; Bullous Pemphigoid has a (-) Nikolsky sign and rarely has mucosal involvement)
causes of high output HF (when CO higher than normal in HF)
*TAP* (heart pumping out like when you repetitively tap the button w/ *HI* freq on controller) Thyrotoxicosis, Anemia/AV Fistula, Preg/Paget bone dz
lateral malleolus fracture classification
*Weber* Classification: level of fibular fx relative to plafond/syndesmosis (the non-movable fibrous joint where distal tibia/fibula join together by connective tissue) A: stable; *below* syndesmosis B: variable stability; *at* syndesmosis C: unstable; *above* syndesmosis all req ORIF but A&B can be discharged with splint (short leg posterior and sugar tong) & ortho f/u
halitosis from trapped food - think -pp -cp -BI Dx test
*Zenker's Diverticulum* -incr P in lower pharynx --> pouch to form -older adult w/ dysphagia, cough, regurg & bad breath -BI Dx: *barium swallow*
Pt w/ dysphagia to solid & liquids who stands after eating & raises their arm above their head to aid digestion - think? -why they did dat -pp -comp -BI Dx test
*achalasia* (rmr this is a motility d/o so will involve both solids & liquids) -why: helps increase esophageal P -pp: esophagus won't peristalse & LES won't relax -comp: esophageal cancer -BI Dx: *barium swallow (bird's beak)*
which caustic ingestion worse? where? & why?
*alkali* - targets *esophagus*; causes *liquefactive necrosis* (whereas acidic causes superficial coagulative necrosis since acid is entering an already acidic env in stomach)
mcc death s/p bariatric surgery
*anastomotic leak* --> peritonitis (usu w/in *10d*) leak of luminal contents from a surgical joining; most imp comp following GI surgery.
when is urinary alkalinizatiom most indicated -how to do this -goal -c/i
*aspirin overdose* -sodium bicarb ggt -aim for urine pH > 7.5 -c/i: think V overload where they can't afford more IVF (pulm edema, cerebral edema) & renal failure
PID regiment Tx
*azithro 1 g PO + rocephin 250 mg IM* -refrain from intercourse for 7d -cefixime alt to ceftriaxone, gentamicin 240 mg IM alt to azithro OR *rocephin + doxy +/- flagyl*
high velocity object to your eye - think -aka -comp -structures to look out for
*blowout fracture* -aka orbital floor fracture -orbit has fat which holds the globe in place but *fat gets displaced = teardrop sign --> enophthalmos* -*infraorbital n.* below the floor --> paresthesias. w/ *inferior rectus & inferior oblique mm.* along floor that can get *entrapped --> diplopia on upward gaze*
child < 5 y/o with no PMHx, nl VS, well appearing w/ new neck mass that arose spont. -NBS -DDx
*branchial cleft cyst - NOT midline* -NBS: O/P removal by ENT -DDx: if fever, think abscess; Thyroglossal duct cysts present as a midline neck mass
give this in strep pneumococcal meningitis too to decr M/M
*decadron*: either *15 mins before or w/ Abx* (bc baterial lysis release inflm mediators which steroids can down regulate)
gluten assoc rash -cp -Tx
*dermatitis herpetiformis* -cp: Pt w/ celiac with pruritic papules (looks like pizza) -Tx: gluten free diet & dapsone
posterior STEMI can be confused with? Cx sign?
*digoxin poisoning* - look for *scooped, down-sloping STD* w/ accelerated jxnal rhythm Think *Salvador Dali (SD)* = *S*TD *D*own-sloped ^(seen most in leads with tall R waves) with incr PR interval and shortened QT
suspected clinical dissection with widened mediastinum on CXR. HR 80, BP 170/90. NBS?
*forget CTA, address the VS IN ORDER* 1) lower *HR 1st to <60*: use *IV BB esmolol, labetalol* 2) lower *BP next to SBP < 120*: use *nitrates or CCB* (Tx BP 2nd as decr BP can cause *reflex tachy* (incr shear forces) which now wont happen since BB given first) 3) now you can order CTA
earliest US finding of preg - seen when
*gestational sac* -seen at 4-5 weeks by transvag -seen at week 6 by trans-ab
Most common fatal gas exposure -cp -found in -pp -HPI clues (2) -Tx
*hydrogen sulfide* (HS) -cp: sewer worker shows up unresponsive -in sewers, swamps & oil refineries -pp: HS bonds w/ Fe --> *inh Mt cytochrome complex* (incr LA) -clues: 1) *discolored copper coins in Pt pocket*; 2) *rotten egg odor* -Tx: (~ CN) = sodium nitrite, amyl nitrite - exchange transfusion & HBO prn
seizing Pt with concern for low BP - use this induction agent
*ketamine 2 mg/kg* (dont use propofol here. ketamine good alternative)
circumoral burn - what is involved? clin pres?
*labial artery hmrg* in kid who chews on electrical cord 2-3 days after when scab prematurely dislodges
MC injured organ in stab wound
*liver* > SI > diaphragm STAb --> AST (liver enzyme) also most stabbers R handed so target RUQ/liver
episiotomy - watch for
*oblique incision* > midline -spares perineum (ie *so you dont cut over anus*)
AVRT: orthodromic vs antidromic
*orthodromic* (85%): anterograde conduction (ie nl forward cond thru AVN) —> signal moves back up BoK from vent to atria (so re-entrant circuit NOT just directly w/in AVN) —> narrow QRS (85%) like SVT *antidromic*: backwards now (ie retrograde conduction thru AVN or antegrade thru accessory pathway ie from A to V) —> wide QRS (only 15%) like WPW -undistinguishable from *VT; Tx: procainamide >* amio (can cause VF)
BLOOD PRODUCTS (4)
*pRBC's*: 1U (250mL) raises Hb +1 g/dl; 15 ml/kg in PEDS *FFP*: contains *all coag Fx + fibrinogen* -indicated when a patient has *MULT Fx deficiencies and is BLEEDING* (eg DIC w/ hi PT/PTT) -INR of FFP = 1.6 so transfusing for INR <1.7 useless *CPP/cryo*: cold concentrated *subset of FFP components*: fibrinogen, Fx8, vWFx + Fx13. so *NOT* just a concentrate of FFP. In fact, a unit of cryo contains *only 40-50% of the coag Fx found in a unit of FFP* -used for hypofibrinogenemia, vWDz; hence *used less* *PCC/KCentra/4 Fx PCC*: Fx 2/7/9/10 -used for *rapid warfarin reversal* (MOA: vit K ant so blocks vit K dep clot Fx = blocks 2, 7, 9, 10 C&S) (in setting of bleeding or need for invasive procedure)
beware damaging this when incising pericardium
*phrenic nerve* --> u/l diaphragmatic paralysis
sonographic murphy sign - good vs bad in SN/SP
*poor SP* hi SN & hi PPV
Pt receiving tPA. while getting Rx, develops HA, decr LOC, N/V, sudden HTN. NBS?
*r/o ICH*: -stop tPA -get STAT CT head -give *10 units CPP + 6 units PLT*
how to Dx aMI if LBBB seen
*sgarbossa criteria*: rule of appropriate discordance -*CONCORDANCE = BAD* = either BOTH UP or BOTH DOWN; both components being: 1) ST segment (with J point) 2) QRS complex (forget T wave) 3 pts = 90% SP for STEMI -discordance is normal. Concordance is bad -rule has one positive concordance (both up), one negative concordance (both down in V1-V3) and one excessive discordance (usu seen with first rule)
clinical indicator of poor prog in radiation exposure lab indicator of same? mc sx in radiation exposure
*the earlier the onset of Sx*, the higher the dose so the worse the prog -48 hr *lymphocyte count. >1200 = good, <300 = bad* mc = GI Sx (N/V/D)
mcc acute ischemia in extremity of an adult greatest risk of thromboembolism in preg is during what period
*thromboembolism* (of cardiac origin) > arterial clot -embolic is INSTANT; thrombosis (arterial even) takes time and mc in chronic thromboembolism in preg during *postpartum*
most SN sign of CES (cauda equina) -pp -mcc -DTR
*urinary retention* leading to overflow incontinence = *90% SN* -compression of peripheral nn. roots S2-S5 -mcc: METS, trauma, abscess, hernia -DTR will be *hypo*reflexive bc peripheral nn. roots
CSF studies for viral meningitis
*viral: LOW PROTEIN w/ NORMAL GLU* - with lymphocytes and neg gram stain
evidence of an medical (ie not psych) etiology for psychosis demograph most likely to successfully commit suicide #1 rFx for suicide mc method of successful vs attempted suicide 2 variants of suicide
*visual hallucinations* (auditory is more 2/2 psychiatric etiology) suicide: old white men rFx: previous attempt mc succesful: firearm; mc attempted: hanging i) silent: silently deteriorating self (eg starvation) ii) occult: self destructive acts disguised as accidents
first true embryonic structure seen via US when is fetal heart activity seen
*yolk sac* - seen at 5 weeks fetal heart = 6 wks
CD4 opportunistic infections
- > 500: CAP - 200-500: *Tb* - < 200 (4): *PCP* (PNA), *Cryptosporidium* (diarrhea), *Candida* (oral), fungal PNA (= *PCC*) - < 100 (2): *Toxoplasmosis* (AMS), *Esophagitis* (HSV, *CMV or candida*) (= *TE*) - < 50 (4): *CMV* (blurry vision), *Cryptococcus* (AMS), *MAC* (cough), *EBV* CNS 1º Lymphoma (= *MCC*) *P*i*CC* *T*h*E* *MCC* (Most Common Cause) cryptosporidium more letters, so with higher CD4 <150 = histoplasmosisOPHTH
flail chest -def'n -a/w -NBS
-*3 (NOT* 2) or more adjacent rib fx's in at least 2 places -pulm contusion -PPV: low threshold to *intubate*
warfarin toxicity -when to expect to see Sx -Tx -if nl in ER, NBS
-*> 6 hrs* - no bleeding expected, nl PT/INR -Tx: vit K (PO vs IV) & 4-Fx PCC/Kcentra (or FPP/CPP) -can d/c but *re-ck INR in 48 hrs*. if normal again, everything OK.
Bells Palsy -CVA -pp -Tx
-*B*ells *P*alsy = *B*oth *P*alsy = facial droop & forehead -pp: peripheral CN7 (facial n.) palsy usu 2/2 virus (varicella) or lyme -Tx: *CS* (w/in first 72 hrs), *anti-viral* (acyclovir - only if Sx severe)
Bilateral Cervical Facet Dislocation -what is it -~ to?
-*C6* facets anterior to C7 facets --> subluxed vertebral body ~ to *spondylolisthesis*
rice water diarrhea -think -a/w -spread by -Tx
-*CHOLERA* -*shellfish* --> large V losses -fecal-oral transmission (spread by food/water) -Tx: IVF + *Abx IFF (large V losses or epidemic)*
chronic diarrhea in AIDS Pt -think -NBS
-*CRYPTOSPORIDIUM* -Tx: start *HAART ASAP*. when *CD4 > 100*, Sx will resolve. (in healthy Pt, Sx spont resolve in < 2 wks)
Pt w/ access to mountain stream water, beavers has 2 wk hx of foul smelling, watery diarrhea w/ fat stools -think -pp -transmitted by -Dx -Tx
-*GIARDIA* -pp: cysts survive in water and water dwelling mammals (beavers) serve as sources of contamination -trans: fecal-oral, anal sex -Dx: *stool Ag* > stool Ova/Parasite (CDC wants 3 O/P to confirm being (+) whereas Ag present regardless of active shedding or not) -Tx: *metro* - Tx *close contacts too*
rapid onset abdominal pain with *pain out of proportion* -think -cp -Dx -mcc -Tx
-*Mesenteric Ischemia* -cp: elderly M or F with PMHx of AF, CAD, DM, HTN min TTP on exam but in severe distress -Dx: CTA -mcc: arterial embolism -Tx: IVF, NPO, b-s Abx, *heparin & papaverine (v/d)*
pre-hospital considerations for snake bites why so many vials in Tx?
-*NO* tourniquet -*immobilize the bitten extremity*: movement --> mm. cx --> incr absorption of venom need hi # vials bc t-1/2 of venom > t-1/2 of anti-venom
wet, wack, wobbly -think? -cp -pp? -Dx
-*NPH*: Normal Pressure Hydrocephalus -DIG: Dementia, Incontinence (urinary), Gait (ataxia) -abnormal absorption of CSF @ arachnoid villi --> enlarged ventricles -LP will have *NL P (duh)*
hip dislocation -mc -clin pres -what's CC usually
-*POSTERIOR* (unlike shoulder) -also *shortened but INT ROT* -knee vs dashboard in MVA
RENAL UA CASTS match: location + Dz -RBC -WBC -Eos in UA -Granular -Hyaline
-*R*BC: glomerular Dz in *R*PGN (nephritic) -WBC: interstitium in *AIN or pyelo* -Eos: interstitium in *AIN* (AIN has both from CBC) -Granular: tubule from ATN (muddy brown) -Hyaline: pre or post renal ARF
new fistula recently placed few days ago --> paresthesia, cold limb with loss of pulse during dialysis -think -pp -Tx
-*Steal Syndrome* -pp: stenosis in aa. distal to fistula w/o adequate collateralization -Tx: surg
mushroom tox - Sx for the following mushroom ingestions?: -amanita -psilocybin -gyromitrin -coprine -orellanine
-*amanita: hepatotoxic* -*psilocybin: hallucinations, euphoria* -gyromitrin: Sz (Tx: vit B6) -coprine: disulfiram-like rxn -orellanine: nephrotoxic
urethral injury -3 signs -NBS if suspected
-*blood at meatus*, hi riding prostate, scrotal hematoma or perineal bruising -if (+): *retrograde urethrogram* (ie *DO NOT PLACE FOLEY*)
what objects in esophagus must be removed ASAP via endoscopy (4)
-*button battery* -*sharp* pointed objects -*mult magnets* (can attract across bowel wall --> perf) -*large* objects (ie *length > 5 cm & width > 2 cm*) *even if XR neg* (esp in first 3) --> NEED *endoscopy* button battery on XR: *double rim* or halo effect
immunosuppressed Pt with cat/dog exposure -bug? -rFx -clin pres -Tx
-*capnocytophaga* - not only bites, but cat/dog licks or even being close. -chronic CS, alcoholics, asplenic Pt -4 wk course that can be flu like to full blown sepsis -Tx: *PCN G* for *3 wks*
wounds at high risk of infxn
-*cat or human* bite not on face (dog bite OK, and bite on face for cosmetic reason can be loosely closed) -bite on *hands or feet* -wounds > 12 hrs (unless on face, then 24 hrs) -i-c Pt for these, *DO NOT CLOSE PRIMARILY, leave open to heal by secondary intention*
knee dislocation -NBS -must ck this
-*consult ortho*, arteriogram & vascular surg consult -ck for pedal pulses and nerve test bc disloc can hurt *POPLITEAL ARTERY* & peroneal n.
Alcohol withdrawal (EtOH w/d) - how soon after last drink do/does: -hallucinations start (visual, auditory & tactile)? -w/d Sz start? -*DT* start?
-*hallucinations 12-24 hrs* after last drink -w/d *Sz 24-48 hrs* -*DT 48-72 hrs* minor sx 6-12 hrs: anxiety, nausea, sweats, *shakes*
Central Cord Syndrome -cause -loc -clin pres
-*hyper-extension* -fx on medial portion of lateral CST (from med to lat goes cervical, thoracic, lumbar, sacral) so fx C/T-spine -*weakness in arms* > legs think CENTER of your BODY ie *ARMS*
which Dz surprisingly don't need airborne precautions
-*inhalation anthrax*: no human to human transmission -meningococcemia only needs droplet
syringomyelia -clin pres -how to make sense
-*loss of PTt in U/E* -combines both anterior & central cord syndromes: anterior (loss of PTt) & central cord (fx arms > legs)
TCA overdose EKG anti-arrhythmic of choice?
-*wide QRS* 2/2 *RBBB* (delayed RV activation from inter-ventricular conduction delays because R bundle more sensitive to Na-channel blockade, causing *RAD*) -*terminal, wide R'* wave (> 3 mm) in *aVR* -anti-arrhythmic of choice: *LIDOCAINE* (class IB anti-arrhythmic) bc it competitively inhibits Na-channel blockade with TCA bound to the R
Digoxin Toxicity -MOA (2) -exacerbated by -presentation differences in arrhythmia -mc assoc arrhythmia and 1st sign of toxicity
-1) *incr force (not duration) of Cx (Na-K ATPase-inh*: incr intracellular [Na] --> decr activity of Na-Ca exchanger --> incr intracellular [Ca] available for Cx 2) *decr HR by stimulating PS @ vagus nerve*: slows down conduction at AV node --> incr refractory period of myocytes --> ventricles more time to fill before Cx -exacerbated by *hypoK*: low K incr Pt susceptibility to the toxic fx of dig -in *younger Pt = brady; older w/ hx CAD = tachy* -mc: PVC
AIN -T/F: Rx can take up to 18 mos to cause Sx -Cx sign on CBC
-18 mos: TRUE -Eos
MG Tx -1LTx -difficult dosing
-1LTx: CS, IVIg, plasmapharesis -problem is block at ACh-R so you want to increase [ACh] via an *AChEi (pyridostigmine)* but bc rapid onset, dosing is tough bc OD yields cholinergic crisis which is similar to myasthenia crisis. both = wknss, SOB focus on *PUPILS*: miosis/constriction in cholinergic, mydriasis in myasthenic; *salivation/lacrimation* incr in cholinergic (SLUDGE-MM), decr in myasthenia
bilious vomiting DDx -1st day of life -1st week of life -1st yr of life
-1st day = duodenal atresia -1st week = volvulus w/ malrotation (most dangerous) -1st yr = intussusception 60% of DaVIn
BURNS classification - 3º, 4 types -layer involved -clinical appearance
-1º (Superficial): Epidermis only; erythema *w/o blisters* (think Sunburn) -2º (Partial thickness - Superficial vs Deep): Prox vs Distal *Dermis*; *blisters but SENSATION INTACT* -superficial blanches (capillaries in tact) but *deep does not blanch (capillaries burned off)* -3º (Full thickness): Hypodermis (involving subQ tissue + muscle); white leathery waxy lesion *w/o sensation* ^needs skin graft (4º: goes down to bone --> req's amputation)
4 classes of blast injuries
-1º: *barotrauma w/o external* injuries -2º: damage from *flying objects* striking body --> penetrating trauma --> obv bleed (most casualties) -3º: *Pt flies* thru air and lands --> penetrating *AND* blunt trauma -4º: all others (smoke inhalation, chemical exposure, *PTSD*/psychological trauma)
2º Syphilis -cp
-2 mos after chancre start having systemic sx (fever, malaise, HA) & *rash involving palms/soles* (CARS) for 2wks-2 mos
Pseudomembranous colitis -think -timeline -how to prevent -cp -Dx -Tx
-2/2 *C. diff* -can occur *6 mos after* Abx use -stop wanton prescribing of Abx (*clinda, amox,* cephalosporin), wash hands, PPE -cp: non bloody diarrhea, ab pain w/ rebound, fever -Dx: immunoassay for stool toxin -Tx: *PO vanco 21d*
Erythema multiforme -mcc -cp -confused w/ -2 types
-2/2 *HSV* infxn or 2/2 *PCN* use -cp: discrete target lesions --> confluent -amoxicillin rash -(2): minor & major (major has *mucosal* involvement)
Croup -cp -mcc -Dx -Tx -avoid this
-6 m/o to 3 y/o w/ viral URI sx (nasal congestion, fever) w/ *barking cough, stridor* -mcc: parainfluenza virus -Dx: neck XR w./ *steeple sign* -Tx: beta-agonist, *Decadron 0.6 mg/kg PO, racemic epi*
febrile Sz -age range -when to LP -comp/@ risk for -rFx for recurrence
-6 m/o to 6 y/o -in status, < 12 m/o w/ no vaccine, meningitis suspected -risk for recurrent febrile Sz, higher (P) of gen epilepsy -rFx: low grade fever (as opposed to hi temp) @ time of Sz, short course of fever (as opposed to long 3d hx)
febrile seizure -age range -rFx -types (2) -Dx
-6 m/o to 6 y/o -rFx: *famHx*, -types (2): *simple:* mc, <15 mins, no assoc wknss; *complex: > 15 mins, a/w post-ictal wknss* -Dx: clinical - neuroimaging & EEG *not rec*
SHOULDER DISLOCATION -mc? -co present with (2)
-95% ANTERIOR -humeral head fx (Hill-Sachs deformity) or less common glenoid rim fx aka Bankart's lesion
NBS for NAC admin in APAP toxicity given following scenarios: -ingestion < 4 hrs ago -ingestion 4-24 hrs ago -unknown time of ingestion or > 24 hrs
-< 4 hrs: if presumed toxic (ie > 150 mg/kg) --> NAC. ck level at 4 hrs to confirm if you have to continue -4-24: ck APAP level. if level avail w/in *8 hrs* of ingestion - wait for level to Tx. *if > 8 hrs, just start Tx* and d/c if levels return normal. -> 24: *start NAC* & *cont if APAP > 10 or incr LFT's*. if *both normal - d/c NAC*
fasciotomy indications where to check P anatomically dispo if compartment P = 25 (ie close but not there)
-> 30 compartment P -< 30 delta P (DBP - compartment P) ^think abt it this way: P in a compartment is only possible if the DBP supplying the area exceeds the compartment P it has to overcome check P as close to fx site as possible dispo: admit for serial checks (NO OBS in ED!)
COPD ABG or VBG? target O2-sat? Abx indications sputum Cx nec? how to decr M&M?
-ABG bc pCO2 not accurate in COPD on a VBG -O2-sat: 88-92%. over oxygenating will decr resp drive -3 cardinal Sx that indicate Abx: severe exacerbation (ie incr dyspnea), change in quantity or color of sputum routine sputum Cx not nec decr M&M: smoking cessation, home O2, Abx, BiPAP
Thyroid Storm Tx Q's -why APAP > ASA -why PTU > MMI (Methimazole) -how does giving iodine work - sounds counter-intuitive
-ASA facilitates conversion of T4 to T3 (bio active form) -PTU not only blocks synth like MMI, but PTU also blocks peripheral conversion & acts quicker; both hepatotoxic but if underlying liver Dz, MMI better -incr [Iodine] leads to transient *decr* of T3/T4
WPW -classification -Cx EKG features (3)
-AVRT anti-dromic (anti so retro thru AVN hence wide QRS but antegrade thru accessory pathway so that's why no AV blockers for Tx) -EKG (3): short PR, *delta wave*, wide QRS
sternoclavicular dislocation -A vs P
-Ant: mc -Post: assoc w/ airway/mediastinal injuries
Jefferson Fx -aka -cause -what is it
-C1 *burst* fracture -axial compression (think unrestrained driver hitting roof of car in MVA) -XR *odontoid* view best: *lateral displacement of articulating pillars*
optic neuritis in MS -CC -prog -Tx
-CC: cant see, eye hurts -more benign long term course -IV steroids (better than PO)
strep pharyngitis -criteria -why we aggressively Tx this? -best analgesic
-CENTOR: *CEFT* (no Cough, Exudates, Fever, TTP LN) 3-14 = +1; 15-44 = 0; > 44 = -1 -prevent rheumatic fever -pain: Decadron
this CN palsy can be "falsely localizing" this CCB for vasospasm of aneurysm in SAH carotid dissection Tx -mc results seen on CSF LP of GBS?
-CN6 palsy = very long n. affected by ICP so "falsely localizing" -nimodipine (PO) -dsxn: actually AC (counter-intuitive); thinking that dissection causes micro thrombi that can shower to brain and cause stroke & AC prevents that -GBS: *hi protein AKA* Albumin-cytological dissoc (hi protein (>45) + low WBC ct (<10)) is most common
HBO (hyperbaric oxygen) indications for CO poisoning
-CNS Sx: LOC, coma, Sz -CO level > 25% (15% in preg) -MI, arrhythmia -end organ dmg -Sx despite Tx
CKD -prog -Tx -a/w -NBS
-Cr in tact *until 4th decade of life* -*no Tx* (no way to slow progression) -a/w *HTN*, UTI, ab wall hernias, *intra-cranial aneurysm* -start the Pt on *ACEi*
AI-mediated pericarditis that occurs in the setting of MI/heart surg -think? -S/S -tx
-Dressler syndrome -fever, hi WBC, *friction rub, pericardial effusion* -tx: CS, NSAID
diverticulitis -mcc -tx -if d/c, f/u instructions -comp
-E. Coli or B. fragilis -Tx: cipro + metro -d/c with PO Abx & on *CLD for 2-3d, advance as tolerated with hi fiber* -comp: abscess
blunt myocardial injury -best SN test -comp
-EKG -arrhythmia
expected A/B d/o in ASA/salicylate toxicity: early, late, net antidote; dose?
-Early: resp center stim --> tachypnea --> *resp alk* -Late: compensatory *HAGMA* -Net: mixed resp-alk & met-acid antidote: *urinary alkalinization* & HD (I-*S*TUMBLED): goal is to incr poison eliminiation by giving IV sodium bicarb to prod basic urine (pH > 7.5). as ASA collects in alk env in urine, begins to ionize/separate & eliminate ^dose sodium bicarb: bolus 1-2 mEq/kg IV, then put 3 amps bicarb in 1L D5W & run it at 2-3 cc/kg/hr
Inguinal Buboes -def'n -think -cp -Tx
-Enlarged LN (up to the size of a tennis ball) -*LGV* (lymphogranuloma venereum) 2/2 *Chlamydia trachomatis* -*painless*-herpes like ulcer w/ *painful* LN's (buboes) -Tx: *doxy 21d* (if *preg azithro* 1 g PO/wk for 3 wks) + *I&D of buboes*
this diarrhea can be mild or p/w severe dysentery --> fulminant colitis -think? -a/w -Tx
-Entamoeba histolytica; leads to bowel necrosis -a/w liver abscess & cerebral amebiasis -Tx: *metro for no Sx, add paromomycin (amebicide) if invasive* (Tx *ALL cases, even no Sx*, bc potential to be invasive + risk of spread to family)
Ovarian hyperstimulation syndrome (OHSS) -cp -how to Dx -NBS -Tx
-F taking fertility meds with abrupt onset distention 2/2 ascites, oliguria, resp distress 2/2 pleural effusion -Dx labs: elevated *HCt, transaminitis, or coagulopathy* (2/2 decr hepatic perfusion) -*ADMIT if HCt > 60% + ascites* -mostly supportive - resolves in 1-2 weeks
radial head fx -mech -Tx
-FOOSH -no surg, just splint
scarlet fever -mcc -cp -Cx pe
-GAS/Strep pyogenes -Pt w/ preceding strep infxn (sore throat) --> fever, *strawberry tongue & sandpaper rash* (w/ numerous small papules) that starts up @ head & goes down -Cx (pic): pastia lines = red streams in axilla & skin folds
bloody diarrhea match -a/w GBS -a/w pseudo-appendicitis -assoc w/ HUS -a/w liver abscess & cerebral amebiasis -loose watery stools that happen to be FOBT -assoc w/ undercooked hamburger, petting zoos -assoc w/ pet turtles & eggs -a/w fecal oral transmission -a/w fulminant colitis/bowel necrosis -a/w erythema nodosum & reactive arthritis
-GBS: campylobacter -pseudoappy: Yersinia enterocolirica -HUS: E. coli -liver/cerebral: Entamoeba histolytica -watery: salmonella (think Salmon in water) -hamburger/zoos: E. coli -pet turtles/eggs: Salmonella -fecal/oral: campylobacter -fulminant colitis: Entamoeba histolytica -EN/ReA: yersinia enterocolitica
CO exposure -CC -1LTx -baseline levels -Cx pe -comp w/ severe exposure -Dx
-HA -1LTx = *HFNC* (t-1/2 of CO on RA is 300 mins, goes down to 90 mins with hi flow, down to 30 mins on HBO) -smokers baseline 10%, non-smoker can be 3% -cherry red lips -severe: MI, arrthythmias, pulm ed, Sz, syncope, coma -Dx: *co-oximetry* (measures CO)
Ellis Classification of dental Fx -how to manage all 3 classes -how is the final class seen?
-I: fx thru *Enamel* (white) --> out-Pt f/u -II: fx thru *Dentin* (yellow) --> *cover w/ calcium hydroxide paste* & out-Pt f/u -III: fx into *Pulp (nn. & vv. sit here)* --> *emergent dental consult; seen as a RED DOT*
DIC (disseminated intravascular coagulation) LABS
-INCR: PT & PTT & D-d (all fibrin degradation products) -DECR: PLT & fibrinogen & Hb (micro will show MAHA (fragmented RBC's/schistocytes)) 3 down, 3 up *BETTER WAY TO THINK ABT DIC = 2 DIFF PROBLEMS* i) *HMRG*: hi PT/PTT, lo Hb (think MAHA = schistocytes) ii) *CLOT*: lo PLT & fibrinogen (getting used up), hi D-d (FDP: meaning ongoing fibrinolysis bc clot exists!)
hyperthyroidism labs
-INCR: glucose (2/2 stress), calcium (thyroid stim --> PT stim), LFT's -decr: *lo cholesterol* (2/2 burning it off)
IO sites in kids vs adults how long can IO stay in 4 stages of disaster plan for hospital
-IO kids: prox tibia; IO adults: prox humerus -IO < 24 hrs otherwise --> *osteo* i) preparedness (planning), mitigation plan (initial axn), response (all steps to solve disaster, *establishing command system*), & recovery
mc solid organ transplant -think -highest risk of opp infxn -if you have anemia, leukopenia, transaminitis - think? -anatomical loc of transplant
-KIDNEY -opp infxn: *during mo 2-6 post transplant* -2/2 *CMV* -retroperitoneal in pelvis
PTA infection --> sepsis -think? -bug
-Lemierre's syndrome -bug: Fusobacterium
MAO-i -MOA -don't mix with -cp
-MAO degrades catecholamines so *MAOi incr SNS* -do *NOT mix w/ tyramine: cheese, fava beans*, EtOH, mepiridine, dextrometorphan -cp: *HTN* crisis 6-12 hrs *after ingestion*
carpal tunnel syndrome -n. involved -rFx -clin dx tests -late stage finding
-MEDIAN -rDx: *RA, hth, preg, DM* -Tinel's (tapping), Phalen's (hyperflex wrists) -*thenar* atrophy (sensory findings before motor)
TdP -mcc -Tx -c/i
-MI -Mg 2-4g *even if levels are NL + overdrive pacing* (speeding up HR narrows QTc) -*NO procainamide or amiodarone* bc *they further prolong QT*
COMPARTMENT SYNDROME -Dx -Tx
-Measure Compartment pressure aka intramuscular P (> *30 mm Hg*). sometimes higher P tolerated so can also use *DELTA PRESSURE*: DBP - Compartment P (*if LESS THAN < 30, it is concerning*) -Tx: fasciotomy
Waterhouse-Friderichsen syndrome -bug -pp
-N. mening -meningococcemia --> b/l adrenal hmrg --> htn, sepsis, DIC, *death*
AFLP (acute fatty liver of pregnancy) -cp -how to Dx
-N/V with epigastric/RUQ pain in *3rd trimester* -get CBC, CMP - look 4 *ab-NL coag's 2/2 liver dysfxn + HYPOGLYCEMIA + HI AMMONIA* (liver has trouble w/ gluconeogenesis + converting ammonia via urea cycle)
auricular hematoma -see this NBS -comp -when to refer to ENT -rmr: why do we pack after Tx
-NBS: I&D and PO Abx for pseudomonas (cipro) -comp: if no Tx --> cauliflower ear (fibrocartilage growth --> permanent deformity) -ENT if >7d old -to prevent re-accumulation
PCP -MOA -Cx Sx -comp
-NMRA-R *ant* -Sx: *vertical nystagmus* -comp: rhabdo, Sz
mc opportunistic infection in HIV -aka -Cx labs -Cx CXR -Tx; backups
-PCP aka P. carinii PNA aka P. jirovecii PNA -labs: incr *LDH* (SN, not sp) -XR: b/l interstitial infiltrates (*bat wing*) -Tx: *bactrim*; if allergic pentamidine for in-Pt (IV or inhaled), primaquine/clinda for out-Pt
HERNIAS -mc in infants/children -close spont @ age of 2 -mc in women than men -high risk of strangulation -exclusive to women, multiparous, after losing a lot of weight -2/2 strangulated Meckel's diverticulum
-PEDS: inguinal vs umbilical -2: umbilical -women: femoral -Strangulation: Spigelian (thru ab ventral fascia) -multiparous: Obturator (p/w medial thigh pain) -Littres
25 y/o M w/ fever, malaise. skin abscess drained 4d ago. hi WBC with infiltrate in RUL but no pulm Sx. -NBS -rFx -pp -Tx
-PNA doesn't make sense so do *CT chest: septic PE* -IVDU or i-c Pt -infxn enters blood stream which travels to lungs -Tx: Abx
painless chancre -diagnosis? -BI Dx tests -MA Dx tests -Tx
-Primary syphilis -BI: *Non-Treponemal, hi SN, screen test*: result is # that you trend to see if responding to Tx. ex: *RPR* -MA: *Treponemal, hi SP*, lo SN: either (+) or (-). once (+), stays so for long time. ex: *FTA-ABS* -Tx: *single shot 2.4M U of PCN G*
coronary artery vasospasm -think? -expected Dx -Tx
-Prinzmetal angina -EKG looks like STEMI but neg trop (opposite of NSTEMI) -Tx: nitrates (decr vasospasm)
TCA OD - bicarb indications (3)
-QRS widening -htn (refractory to IVF bolus) -ventricular arrhythmias
Pt w/ chest pain (inferior STEMI) w/ new onset mumur & pulm edema -think? -pp? -Cx EKG -cp -c/i
-RV infarct -*acute papillary mm. rupture* -STE in *lead III* > lead II (lead th*R*ee highly suggestive of *R*V involvement) -signs of CHF (pulm ed, JVD, htn) -no morphine or NG (preload dependent); IVF ok
ear pain with vesicles in auditory canal -think -aka -sx -Tx
-Ramsay-Hunt syndrome -herpes zoster oticus -i/l facial paralysis -Tx: same as Bell's - CS + antiviral
million dollar n - think? fxn? the British n.? -deep fibular n. Innervates? -snowboarder's fx aka
-Recurrent median n.: pure motor - *OAF* (opp, Ab, flex); rmr median n. innervates thenar eminence -Median n. - think for British/tea drinking: check for pronators, princer grasp, flexor at wrist -deep fibular n. for first digit space -snow: lateral talus fx
Anticholinergic Toxicity -Rx that cause it (3) -way to rmr this -way to distinguish this from similar one
-Rx: antihistamines, antipsychotics, antidepressants -"*Blind as a Bat, Mad as a Hatter*, RED DRY HOT" -AC: *HYPO*active BS & *NO* Sweating; SYMP: *HYPER*active VS & *S*weats for *S*NS
Neuroleptic Malignant Syndrome -precipitating Rx -pp -Cx Sx -Cx Dx -Tx
-Rx: neuroleptics/typical antipsychotics (*haldol*) -from *DA ant*agonism -TETRAD (*HARD*): *Hyperthermia*, AMS, *"lead pipe" Rigidity*, Dysautonomia (HTN, tachy, sweats) -Cx Dx (not in SS): *hi CPK & WBC* -Tx: benzos for agitation, *dantrolene* (sk mm relax) for rigidity, *bromocriptine/amantagine* (DA-agonists)
Serotonin Syndrome -precipitating Rx -pp -Cx Sx -Tx -c/i
-Rx: serotonergic (SSRI, MAOi, SNRI, TCA), Reglan, Zofran, Fentanyl, Triptans -pp: serotonergic surge -Sx: GI Sx (N/V/D), AMS, *Hyper-reflexia w/ Clonus*, Dysautonomia (HTN, tachy, sweats, Hyperthermia) -Tx: benzos for agitation, *Cyproheptadine (5-ht ANT)* -c/i: hold anti-pyretics for fever
mastitis -mcc -NBS (if mom of neonate) -Tx
-S. aureus -NBS: obtain nipple Cx -Tx: *cont breast feeding* + Abx (*keflex*, dicloxacillin)
appendicitis/appy -most SN finding -most freq missed Dx -clin pe signs
-SN: RLQ pain -missed Dx: AGE -(3) rovsing, obturator (int rot of R flex thigh), psoas (hip ext)
hyponatremia Tx -if severe sx -alt -rate -comp
-Severe Sx: *100 mL of 3% NaCl* IV over 10 mins × 3 prn -sodium bicarb ~6% NS so you can give half (50 cc 1 amp) over same time to deliver 50 mEq Na -rate: incr no more than 0.5 mEq Na an hour -comp = *central pontine myelinolysis*:
Opioid toxicity -Sx -Tx (dose?) -This Rx can mimic opioid overdose
-Sx: resp depression, miosis (pupil constriction), htn, comatose -Tx: *narcan* starting dose 0.05mg IV, apneic 2 mg IV -Rx mimic: CLONIDINE
Pt with PMHx of Tb has first time Sz -think? -NBS
-Sz 2/2 *INH toxicity* (Isoniazid/INH = Injures Neurons & hepatocytes) -give vitamin B6 (pyridoxine)
status epilepticus -def'n -mcc
-Sz activity *>20 mins* or *back to back* Sz *w/o inter-ictal period* -mcc: sub-therapeutic drug levels
Pt with kidney transplant hx now has UTI -NBS -c/i -if anemic, NBS -if c/o limb pain
-Tx w/ b-s Abx (dual vanco, zosyn) -*AVOID nephrotoxic Abx: aminoglycoside (gent)* & hi-dose TMP/SMX -anemic: use *leukocyte-depleted* blood -get *XR: chronic CS --> fx*
ideal Pt for non-surg mgmt of ecoptic (4)
-VSS -hcg < 5K -ectopic size < 4 cm -no fetal cardiac activity
tumor lysis syndrome -labs -cp -Tx -Px -c/i
-WT*PUCK* or pour a *KUP* of e- into bloodstream: hi K, hi Uric acid, hi Phosphate, low Ca -cp: Pt w/ hi grade lymphoma (ALL, NHL) 12-72 hrs after chemo -Tx: *IVF* -Px: Rasb*uric*ase if high risk (decr uric acid) -c/i: caution w/ *Ca* --> can precipitate out with Phos
bloody diarrhea w/ RLQ pain -think -sequelae (a/w)
-Yersinia enterocolitica hence *pseudoappendicitis* -a/w erythema nodosum & reactive arthritis
Methadone -a/w -t-1/2
-a/w *prolonged QT* so watch for *Torsades* -t-1/2 *very long* (ie > narcan) so may need *mult doses*
toxic megacolon -a/w with -pp -CC -Dx -c/i -Tx -comp
-a/w Ulcerative Colitis or infectious C diff colitis -pp: decr in bowel wall tone -CC: severe bloody diarrhea -Dx: colonic dilation > 6 cm -c/i: anti-motility agents, opioids, anti-chol Rx (promotes more constipation so stops peristalsis/tone) -Tx: IVF, *CS, Abx* -comp: colectomy
Herpes Zoster Ophthalmicus -a/w
-a/w shingles
Shigella -cp -pp -Tx -c/i
-ab pain, fever, bloody diarrhea -*efficient* pathogen: small inoculum --> infxn -Tx: *Abx* (if sick or Cx confirms) w/ *IV rocephin or PO azithro* -*avoid loperamide* (worsens diarrhea)
cholesteatoma -what is it -cp -NBS/Tx
-ab-nL growth of Sq epith in middle ear/mastoid -cp: u/l hearing loss w/o pain w/ hx recurrent OM -Tx: SURG so NBS consult ENT for outpatient f/u
mitral regurg -types -murmur Cx
-acute (chordae tendinae rupture, papillary mm. dysfxn) vs chronic (rheumatic heart, mc) -murmur: systolic MR AS, diastolic AR MS - *loud holosystolic murmur rads to axilla*
HACE (high altitude cerebral edema) -sequelae to -cp -1LTx -Px/Prophylaxis
-acute mtn sickness after Pt cont to climb -cp: *ataxia, N/V, AMS, Sz, coma* -Tx: *DESCENT = 1LTx* - begin STAT. also steroids *(decadron) & mannitol* (to diurese edema) -Px: *acetazolamide*
HCG -how soon can it be detected after ovulation -doubles when? -declines when? -detectable for for long after preg?
-after ovulation: 6-12 days -doubles: every 2-3 days for first 10 wks -declines every 2-3 days for next 10 wks -up to 2-3 weeks POST delivery
infantile spasms -age -Dx -Tx -prog
-age: 3-8 m/o; -Dx: EEG; -Tx: ACTH; prog poor (33% mortality rate)
sudden onset hypoxia, near syncope with unstable VS after central line placement -Dx? -Tx -^exception
-air embolism -hi flow O2 100% (NRBM), put in *LLD & Trendelenburg* (ie Durant's Maneuver - Traps air in apex of RV (air rises), relieves obstruction from pulmonary outflow tract) -if know to be aa., then keep flat & supine
DIC -aka -mcc -Tx
-aka CONSUMPTIVE COAGULOPATHY (factors being used up ineffectively) -mcc: i) sepsis; ii) head trauma; iii) cancer; iv) OB issue -Tx: underlying cause. *may need FFP/PLT* rmr FFP contains ALL Coag Fx's + fibrinogen
Roseola Infantum -aka -cause -cp
-aka Exanthem Subitum (latin for SUDDEN RASH) -cause: HHV-6 (human herpes virus) -2-3d prodromal *hi fever, then DEFERVESCENCE --> rash starts on body* and moves up to face for 1-2d RIES: Roseola Infantum, Exantm Subitum -rash RISES out of nowhere, RISES up body to face
Osler-Weber-Rendu syndrome -aka -gen -cp
-aka HHT: Hereditary Hmrg-ic Telangiectasias -AD -*CC: epistaxis* a/w telangiectasis of MM, skin & GI tract causing *recurrent GI bleeding*
psuedotumor cerebri -aka -pp -clin pres -Cx PE sign -Dx -Tx
-aka IIH: idiopathic intracranial HTN -pp: impaired CSF absorption --> increased CSF V & P -young obese black F w/ PCOS/irreg menses w/ HA -papilledema (b/l symmetric) -LP w/ hi OP (> 25) -Tx: wt. loss, *acetazolamide, loop diuretics* (to drain fluid out), CS; shunt if refractory
Reactive Arthritis -aka -triad -saying -prodrome -Dx -Tx
-aka ReA aka Reiters Syndrome -triad: conjunctivitis, urethritis, arthritis" -"Cant see, Cant pee, Cant climb a tree" -preceding infxn (urethritis, cervicitis) -Dx: UA, GC swab, stool sample -Tx: NSAID (*indomethacin*)
guyon's canal -aka -what is it -why imp -cause -Tx
-aka ULNAR TUNNEL SYNDROME -ligament from pisiform to hamate (sltP,Hctt) -contains ulnar n. so think N/T in ulnar distribution -repetitive trauma/use (bike handlebars, holding fold clubs) -NSAID, splint, surg
trench mouth -aka -cp -mcc -rFx -Tx
-aka Vince's Angina = Acute Necrotizing Ulcerative Gingivitis -cp: *halitosis*, loss of contour of interdental gingiva w/ *ulcerative necrotic sloughing of gingiva* -mcc: usu Polymicrobial & *anaerobes* -rFx: i-c, poor PO hygeine, smoking -Tx: irrigate/debridge necrosis, *Abx (metronidazole)*
Ogilvie Syndrome -aka -cp -pp -Dx -Tx
-aka acute colon pseudo-obstruction (ie acute LI non-mechanical obstruction) -cp: elderly bedridden patient -pp: autonomic dysfxn --> decr cholinergicity -Dx: XR = massive dilation of the colon (> 10 cm) w/o mechanical obstruction (hence pseudo) -Tx: colonic decompression via tube + *neostigmine* (PS-mimetic: reversible *AChEi* so incr ACh)
dry socket syndrome -aka -what is it -NBS
-aka alveolar osteitis -cp: 1-3d s/p *dental extraction* --> exposed alveolar bone d/t *absence of clot over socket = pain* refractory to PO analgesics w/ LN and gingival swelling but *NO fever/facial swelling* -irrigate with warm saline (to remove any debris particles), fill with viscous lido
IRITIS (inflm of iris) -aka -what is it -cp -Cx pe -Dx -tx -a/w
-aka anterior uveitis -Inflammation of iris and/or ciliary body -cp: severe eye pain w/ tearing -pe: *consensual & direct photophobia* (ie light shone in NL eye also causes photophobia) + *misshapened pupils* -Dx: split lamp shows cell (WBC) & flare (foggy appearance of protein, leaked from vessels) -Tx: topical cycloplegic (atropine) + topical CS -a/w HLA B-27 (*ank-spond*)
boutonniere deformity -aka -describe finger -Tx -how it gets its name
-aka extensor tendon central slip/tear -PIP flex, DIP hyper-ext (/\) -splint: put PIP in ext to *straighten finger* -bc injury causes prox phalanx to protrude thru like a finger thru a buttonhole/boutonniere (French)
temporal arteritis -aka -clin pres -a/w -BI vs MA Dx -Tx
-aka giant cell arteritis -cp: elderly Pt with HA & *temporal a. TTP* -a/w *PMR* (polymyalgia rheumatica) -BI: ESR; MA: temporal artery biopsy -Tx: CS (don't wait for bx results)
RABIES -transmitted by what animals -T/F: rabies can only be spread thru broken skin
-almost all mammals (except rodents, chipmunks); no reptiles, amphibians, birds -TRUE: need break in skin
patellar dislocation -loc -Tx -d/c with
-almost always displaced *laterally* -*rdxn*: extend knee and push medially -give Ibuprofen + knee immobilizer (as they freq recur)
red man syndrome - what is it? cp? pp? NBS?
-anaphylaction rxn to vanco -cp: pruritic erythema to face, neck, torso -pp: histamine release -Tx: anti-histamines (benadryl) + *STOP infusion STAT* (restart and *go slower ONCE Sx resolved*)
ANTIDOTES -anticholinergics -organophosphates -aspirin/barbiturates -TCA -CO -CN -Hydrofluoric acid -Iron -Lead -Mercury
-anticholinergics: PHYSOSTIGMINE -OP (cholinergic crisis): ATROPINE + 2-PAM -ASA/barbs: URINE ALKALINIZATION + HD -TCA: SODIUM BICARB -CO: HBO (HYPERBARIC) or 100% O2 -CN: HYDROXY*C*OBALAMI*N (CN)* + SODIUM THIOSULFATE (backup amyl & sodium nitrite) -HF: CALCIUM GLUCONATE (gel) -Iron (*Fe*): DE*Fe*ROXAMINE -Lead: *L(ED*TA), SUCCIMER -Mercury: DI*MERC*APROL (DMSA)
ECZEMA -aka -pp -famHx notable for -1LTx
-atopic dermatitis -pp: T1 Hypersensitivity -famHx: allergies, asthma -start *low potency topical CS = hydrocortisone* (can use hi potency (triamcinoclone or bethamethasone) if severe *BUT NOT ON FACE*)
endophthalmitis -what is it -mc cp -Cx pe -mcc -NBS
-bacterial/fungal infxn w/in entire eye -cp: 6 wks *post-cataract* surgery --> eye pain, visual sx -cx pe: hazy retina on exam -mcc: coag-neg *Staph* -NBS: consult ophtho -needs *intra-ocular Abx*
-2 main tox plant
-belladona = pic = anti-choll; psilocybin = mushroom = LSD
bladder rupture -mc loc -absence of this r/o rupture
-bladder dome -*hematuria* (if present, 100% SN)
severe otalgia w/ OM - now see vesicles and bullae on TM -think -mcc
-bullous myringitis -mcc: *mycoplasma*
LIGHTNING INJURY -assoc burns -pathognomonic signs -how to deal with lightning strike MCI
-burns: superficial only -lichtenberg figures aka ferning pattern (pic) -do opposite of trauma MCI and address primarily ones that are apneic *bc unless already in arrest, almost always survive*
MS -mcc of flare -Tx of flare -caveat
-cause: infxn -flare: hi dose CS Solumedrol 1g IV qd for 3d -Pt becomes less responsive to CS over time
similar story as previous but ocular Sx & fever -think? -pp? -mc bug -clin pres -Tx
-cavernous sinus thrombosis -pp: infxn spread from from nasal/paranasal sinus -S. aureus -ocular Sx (*proptosis & photophobia* w/ CN 3-6 deficits) -Tx: AC (heparin) + Abx
ludwig angina -what is it -mcc -rFx -Cx pe -Tx
-cellulitis of submandibular space -mcc: polymicrobial (follows tooth abscess) -rFx: poor dentition -Cx pe: swelling, pain, hardening of floor of mouth under tongue *w/ absent LN* -Tx: b-s Abx, airway
30F has gradual onset HA w/prog Sz, focal deficit, LOC/AMS over 4d -think? -rFx -DX -Tx
-cerebral venous thrombosis -rFx: OCP use, coagulopathies, pregnancy -Dx: *MRV* (look at bottom for *empty delta sign* in superior sagittal sinus); CTV is backup -Tx: heparin
painful chancre -think -cp -Tx
-chancroid 2/2 Haemophilus ducreyi (makes you *CRY*) -tender papule becomes *painful ulcer* w/ painful LN's -Tx: same as *PID* (covering for GC/Chlamydia) so azithro 1 g PO or rocephin 250 mg IM
choledocholithiasis main complication -think? -pp -mcc -clinical group of sx -how to best Dx -NBS
-cholangitis -obstructed CBD (usu 2/2 stone --> allows bacteria to ascend up *from duodenum*) -mcc: *E. Coli* -charcot triad: fever, jaundice, RUQ; reynolds pentad: add confusion + htn (*50% mortality*) -Dx: *ERCP* (Endoscopic retrograde cholangio-pancreatography) -IV Abx + surg consult
if hx torsion type sx - think? pp? NBS?
-chronic intermittent torsion -pp: segmental ischemia of testicle -NBS: *outpatient* urology eval
botulism -bug -pp -cp
-clostridium botulin -pp: prevents ACh release -focus on *eyes*: early ocular involvement (ptosis, fixed dilated pupil, diplopia, blurred vision, photophobia) + *symmetric, descending* motor wknss *w/ arms* > legs
Plafond/Pilon Fracture -what is it -cause -must r/o this -comp
-comminuted distal tibia fx -strong axial force that drives talus into tibial plafond (articular surface of tibia on talus); ie falling from height -a/w other fx: fibula, calcaneus, vertebral body, pelvis -post traumatic arthritis
Kawasaki disease -comp -if only 2/5 Sx present -Tx; when?
-comp: coronary artery aneurysm -then it's "incomplete Kawaki's" but *still @ same risk for coronary artery aneurysm* -Tx: *IVIg* + *hi*-dose *ASA (100 mg/kg*; start w/in 10d of Sx), +/- CS
complication (ie must r/o) in pericarditis
-comp: r/o pericardial effusion via echo
tension HA -clin pres -distinguishing features from migraine -Tx -prophylaxis
-constant, b/l pain; described as "vice-like" band around head -also no N/V, photophobia -tylenol + caffeine -amitryptiline
MEASLES -cp -contagious timeline -spread by
-cp (3): prodromal hi fever w/ Sx (*+ 4 C's: C*ough, *C*oryza (runny nose), *C*onjunctivitis + *C*/Koplik spots), then + *top-down rash* (starts on head & spreads downward) starts day 4, last till day 7 -contagious 4d before & after rash appears -spread by air (cough, sneeze) so need *droplet precautions*
UV keratitis -cp -dx -tx
-cp: "snow blindness" in skiers, welders, tanning booth w/ *Sx occurring 6-12 hrs after exposure* -dx: fluorescein shows *diffuse b/l punctuate keratitis* -tx: analgesics (cycloplegics ie atropine, scopolamine help w/ photophobia but avoid bc pupillary dilation lasts for days which also --> pain) & topical Abx
migraine -clin pres -rFx -Tx
-cp: *POUND* (Pulsating/throbbing, Onset/duration 3h-3d, u/l, N/V, disabling) w/ photo/phonophobia -F, 10-30 y/o, (+) famHx -Tx: triptans 1LTx; add NSAID better
Campylobacteri -cp -transmission -a/w
-cp: *peri-umbilical* cramping w/ bloody diarrhea -trans: *fecal-oral* so think *food/water poisoning* -a/w GBS
CN3 palsy (oculomotor) -cp -if new, NBS
-cp: *ptosis, mydriasis* (dilated), *eye is DOWN & OUT* -new - concern for *posterior communicating artery aneurysm* so need *MRA/CTA*
SSSS -cp -pp -pe: -Tx
-cp: 3-7 d/o febrile Pt w/ diffuse blanching erythema starting around mouth -pp: *Staph aureus exfoliative toxins* -pe: fragile bullae that rupture on own ((+) Niokolsy) -Tx: *nafcillin, oxacillin* (IV PCN-ase resistant PCN)
Leriche syndrome -cp -pp -Sx (triad)
-cp: 30-40 y/o M w/ triad of Sx -PAD focally in distal abdominal aorta as it transitions to common iliac a. -triad: impotence, claudication in pelvis/thigh, absent femoral pulses
Bronchiolitis -cp -mcc -Tx: non-severe vs severe -avoid this
-cp: < 2 y/o with viral prodrome followed by *wheezing, retractions* -mcc: RSV -Tx non: supp (O2, *nasal sxn*) -Tx severe (ie resp distress) req hosp - give *1 time trial of b/d* -*avoid CS*
mc viral STD in US -cp -aka -main rFx -comp -Tx
-cp: Anogenital warts -condyloma acuminatum -rFx: mult sex partners -comp: anogenital cancers -Tx: *imiquidmod, cryotherapy*
Digoxin toxicity -cp -Tx -indications for Tx
-cp: GI Sx, *hyperK* -Tx: *digibind*; phenytoin & lidocaine help too -arrest, fatal dysrhythmia, *K+ > 5 (lower than you expect)*, > 10 mg ingestion in adult or 5 mg in peds
superficial thrombophlebitis -cp -NBS -Tx -comp
-cp: IV placed few days ago --> new palpable cord -US to r/o DVT -Tx: warm compress & NSAID -may need AC if L/E STE has (3): venous segment *> 5 cm*, proximity to deep venous system *< 5 cm* or *thrombophilic* (ie rFx for DVT formation)
Aortic Stenosis -cp -murmur Cx (3) -avoid these Rx -use these Rx
-cp: SAD (syncope, angina, DOE) -murmur (3): systolic, crescendo-decrescendo, rads to carotids -avoid: CCB, NG, BB (unless angina then its OK bc otherwise you decr HR and cant meet demand) -use: hydralazine for high BP, phenylephrine for htn
Botulism -cp -pp -Tx
-cp: floppy baby after eating honey or canned foods w/ *descending paralysis* or adult w/ diplopia, dysarthria, ptosis -pp: heat labile neurotoxin -Tx: antitoxin
prostatitis -cp -pe -Dx -mcc -rFx -Tx
-cp: middle aged/young M w/ urinary Sx, fever, rectal/perineal pain -pe: prostate firm, edematous, very tender -Dx: *UA w/ pyuria but NO hematuria* -mcc: *< 35 = ginirrhea/chlamydia*; in *> 35 = E. Coli* -rFx: mult sex partners, unprotected anal, BPH -Tx: *6 wks Abx* (at least FOUR)
Black Widow Spider Bite -cp -comp -Tx -dispo
-cp: pinprick sensation over bite (meaning Pt usu *witnesses the bite*, unlike brown recluse) --> in 1 hr, erythematous target lesion --> myalgia, sweats, N/V -comp: *resp fail* can occur -Tx: analgesia (IV opioids), *benzo for mm. cramps* -if severe envemonation, ADM for *anti-venin*
hypokalemia periodic paralysis -cp -cause -similar to
-cp: pure mm wknss, normal sensory, loss of DTR's -cause: hi carb meals, exercise, fasting -thyrotoxic paralysis (2/2 HTH)
SINUSITIS -cp -mcc -Dx? indications? -Tx? indications?
-cp: purulent nasal d/c, sinus TTP, maxillary/tooth TTP -mcc: viral (hence Abx hesitation) -Dx: clin but if comp get CT (ie vision sx, peri-orbital edema, severe HA, AMS) -Tx: *augmentin IFF Sx > 10d*: 5-7d course in adults, 10-14 in PEDS
BB OD -cp -1LTx? MOA? -2LTx? MOA? last line Tx (if still refractory)? MOA
-cp: symptomatic *brady + htn & HYPOglycemia* (AMS) -1LTx: *hi dose glucagon* (think hypoglycemia); MOA: Glucagon *incr HR + myocardial Cx + improved AV conduction* these fx *bypass beta-blockade* -2LTx: *hi dose insulin + GLU* (incr <3 Cx --> incr CO); *intralipid fat emulsion if refractory* (act as lipid sink, attracting Rx away from tissues; more effective in *lipophilic Rx ie propranolol* > metoprolol)
RMSF - cp? Tx?
-cp: tick bite --> petechial rash (incl palms/soles) -Tx: doxy (like Lyme; if preg can max doxy to 14d)
HIT (heparin induced thrombocytopenia) -cp -T/F: spont bleed is expected -cx pe -T/F: LMWH or unfractionated cause equal (P) of HIT
-cp: usu w/in first 10d of Tx --> PLT count drops by > 50% -F: PLT count usu doesnt go < 20K so no bleeding expected (*unlike in ITP where PLT < 20K so bleeding IS expected in ITP*) -pe: *skin necrosis at site of heparin injxn* -F: LMWH is much less (P) for HIT
metallic foreign body/rust ring -cp -Tx -comp
-cp: welder -Tx: cotton tip to remove metal and then Tx as corneal abrasion (topical Abx) -comp: rust ring can form w/in 24 hrs (pic)
Pheochromocytoma -cp -BI Dx -BI Tx
-cp: young Pt w/ *triad of "EPISODIC" HA, sweats, tachy* w/ poorly controlled BP/*HTN* -BI Dx: *24 hr urine for catecholamines/metabolites* -BI Tx: control BP - *⍺1-blockade 1st* w/ *phenoxybenzamine or phentolamine* (backup is doxazosin/terazosin). *then BB*. (eventually needs surgical rsxn)
epididymitis -cp -key distinguishing pe feature -Dx
-cp: young sexually active M localized to testicle -pe: *NL cremasteric reflex* (unlike torsion) -doppler: US shows *incr blood flow to epididymis*
Tet spell -def'n -Tx -if severe, what Rx
-cyanotic episodes caused by *decr in SVR* 2/2 exhaustion from crying, pooping, exertion while feeding, fevers, dehyd --> infant lethargic --> no SVR so incr R to L shunt (exacerbates the cycle) --> Pt spirals down to Sz, *death* -Tx: hi-flo NC (O2 decr PVR), consoling child, *place in knee-chest (squatting) position to incr preload & SVR* (by compressing against abdominal aorta) -Rx: morphine IM (to help console)
pulm HTN -def'n -MA Dx -mcc -Tx goal; Tx
-def'n: *pulm a. P > 25 @ rest*, or > 30 with exercise -Dx: *R heart cath* (gold standard) -mcc: 1º rare, 2º is 2/2 resp or cardio causes (COPD, valvular abnormalities) -Tx: maintain RV filling P; epoprostenol (PG to v/d pulm a.)
Balanoposthitis -def'n -rFx -NBS -Tx -comp
-def'n: inflm of glans penis (balanitis) & foreskin (posthitis) -poor personal hygiene, *uncircumcised* -NBS: *ck GLU* to r/o DM -keep clean & dry, *topical bacitracin & clotrimazole* -if left un-Tx'd, *phimosis*
massive hemoptysis -def'n -mcc: US vs worldwide -airway mgmt -who to consult
-def: > 600 cc in 24 hrs -mcc US: bronchitis; mcc world: Tb -Airway: i) bad, bleeding lung goes *DOWN; ii) sxn & position; iii) *main stem intubate the good lung w/ large ETT (8.0)* which will allow for... iv) *bronch* -IR (embolize a.?), pulm (for bronch), CT-Surg
ToF -collection of defects (4) -pp -cp
-defects (4): *PROV*e = Pulm valve stenosis (causing RV outflow obstruction), RVHT, Over-riding aorta, VSD -pp: causes R-->L shunt via VSD --> cyanosis (blood never gets oxygenated 2/2 RV obst) -cp: cyanosis may or may not be at birth
ketamine -moa -A/E -benefits
-dissociative agent -A/E: emergence rxn - vivid dreams, floating sensation (Tx'd w/ versed); incr ICP/BP/HR -good for *intubating in status asthmaticus* (bc promotes b/d), maintains gag reflex
mc form of diving related injury 3 types of barotrauma a/w scuba diving
-diving: BAROTRAUMA 1) air embolism 2) decompression sickness (aka Caisson's Dz aka The bends) 3) Nitrogen Narcosis
Iron Toxicity -toxic dose -Dx -Tx
-dose: > 40 mg/kg -Dx: KUB with radio-opqaue pills seen -Tx: can start w/ WBI; *antidote = Deferoxamine*
seizing preg F -think -timeline -NBS
-eclampsia -up to 6 weeks post-partum -Mg 4-6 g IV
endometriosis -def'n -mc -MA Dx
-ectopic endometrial tissue -mc at ovary (Chocolate colored) -Dx by direct visualization
LVAD -indication -main 2 comp
-end stage CHF -1) pump thrombus: incr pump readings, decr flow, hot to touch. Tx w/ AC (hep & maybe tPA) 2) driveline infxn: site that exits chest wall @ 2w-2m
sharply demarcated cellulitic rash on face -think -mcc -Tx
-erysipelas -GAS -dicloxacillin, erythromycin
baby acne -aka -describe -(P) seen -Tx
-erythema toxicum -blotchy red spots w/ overlying white/yellow papules (not pustular) -50% of term newborn have it -Tx: supp (self limited)
Pt with a left sided PTx w/o rib Fx -think? -NBS? -expected clin pres? -expected imaging?
-esophageal injury (t*R*achea on *R*) -gastrograffin (water-sol contrast) swallow study (rmr esophagram --> mediastinitis) -odynophagia/dysphagia -subQ on CXR
Mechanisms of heat loss - transfer of heat
-evaporation: from you to atm via vapors (sweating) -conduction: thru solids. from object to object by direct contact (you touch kettle) -radiation: how heat moves thru where there are no molecules via waves (sitting under sun, EM waves) -convection: thru a fluid medium (gas or liquid). from hot to cool via currents (boiling water at bottom hottest first, gets less dense, rises to top, then cool water falls gets heated and also reaches boil)
Cushing syndrome (Hyperadrenalism) -problem -cp -Dx -Tx
-excess cortisol prod 2/2 prolonged CS use, adrenal neoplasm or paraneoplastic dz (SmCC prod ACTH) -cp: *truncal obesity*, HTN, hirsuitism, hyperNa, *moon facies, buffalo hump, purple striae* -Dx: hyperNa + *dexamethasone suppression test* (decadron given, COR measured (should decr if NL) but if persistently high, that's (+)) -Tx: stop CS, address underlying cause
mallet finger -describe finger -if long term - name? -cause -problem -Tx
-ext PIP, flex DIP (--\) -swan neck deformity -direct blow to finger tip (basketball 'jamming' finger) -ext tendon rupture or avulsion fx @ base of distal phalanx --> unopposed DIP flex -Tx: splint DIP in ext to *straighten finger*
tularemia -mc cp ^this form a/w? -transmission -Tx
-fever + *ulceroglandular form* (skin ulcers at site of entry along with regional LN's) -tick bites -transmission dictates Sx if inhales (PNA), ingestion (oropharynx sx) but *no human to human* -Tx: *Streptomycin* for 10d
Sz types
-focal/partial - simple: no LOC, < 15 mins, no focal Sx -focal/partial - complex: may have LOC, > 15m, focal sx -generalized: absence, myoclonic, tonic-clonic, atonic
when is rhogam indicated? dose? exception?
-for pregnant bleeding mother who is Rh (-) -< 12 wks give 50 mcg; > 12 wks give 300 mcg -no need to give *if both mom & dad Rh (-)
fractured penis -mcc -pp
-forceful sex (reverse cowgirl) -rupture of *tunica albuginea* (tight outer sheath of corpora cavernosa)
struvite stones -what do they form? -a/w -found in
-form *staghorn calculi*: branched stones that fill all or part of renal pelvis & branch into several calyces -a/w *proteus infxn* -found in urine w/ *hi pH*
Hydrocarbons -found in -types (2) -mc Sx -comp -dispo
-found in fuels, paints, paint removers, rubber cement -1) *aromatic: circle* arrangement; 2) *aliphatic: linear*/branched arrangment -Sx: sniffing 2/2 lung involvement -comp: aspiration --> *systemic toxicity (if aromatic)* -dispo: if CXR (-) and obs for 6 hrs --> d/c
Arsenic -found in -expected Sx from toxicity -Dx -Tx
-found in wood preservatives, weed killers, pesticides -a/w *mees lines*, peripheral neuropathy, anemia, *alopecia* -Dx: 24 hr urine -Tx: chelate (DMSA - same as mercury)
COMPARTMENT SYNDROME -causes -mc areas -clin pres
-fx (even open), crush injury, high P injection, tight casts, burns, snake bites -TIBIAL & FOREARM (analagous areas) -*6 P's*: *1st is Pain*, paresthesia (also early); then pallor, paralysis, poikilothermia (inability to regulate body temp - this one debatable), *Last is Puslelessness*
Hangman's fracture -what is it -cause
-fx of *C2 pedicle*/spinous process (technically b/l pars inter-articularis) -hyper-*ext*ension injury (think literally hanging someone so *noose rides UP the neck* to C2)
Pt falls & has foot fold under her w/ *(-) XR but persistent midfoot pain* -what is it -NBS -why imp
-fx of *Lisfranc* joint complex: formed by *base of 1st & 2nd MT & cuneiforms* (all medial) -get weightbearing XR films or *c/l films to compare* -most need ORIF so delaying Tx can lead to significant life long cons
boxer's fx -problem -Tx?
-fx of neck of 5th metacarpal -reduce: flex 5th MCP to 90º. downward P on metacarpal shaft + upward P on phalange (pg 12)
jammed thumb -aka -problem -clin exam -complications? -Tx -assoc w/
-gamekeeper's/skier's thumb -tear in ulnar collateral ligament -decr in opposition (index finger to thumb) ie wknss in princer grasp -stener lesions -partial tear: rest + thumb spica; full tear: surg -assoc w/ avulsion fx at thumb base
Bakers Cyst -problem -confused with -NBS
-gastroc bursa enlarged --> popliteal fossa swelling -DVT (if cyst ruptures, leads to acute pain w/ erythema, warmth, calf TTP) -US to r/o DVT
hypertrophic cardiomyopathy -gen -cp -CXR/EKG -Tx
-gen: AD -cp: sudden cardiac death --> VF/VT -CXR: nl, EKG: LVHT + *dagger-like "septal" q waves in lateral leads* -Tx: BB + ICD
HEAT STROKE Mgmt -T/F: anti-pyretics hasten cool down
-goal to lower core temp to 39º C (102.2) -*BEST*: evaporative techniques (water spray, fan) + *ice water immersion* F: *AVOID* anti-pyretics
mc vascular access complication with dialysis Pt -think? -NBS -Tx
-graft stenosis/thrombosis -Dx for NBS: angiogram -Tx: surg, lytics prn
Hep B markers -hallmark for Dx -indicates acute infxn -checks for immunity -high infectivity/virulence
-hallmark: *HBsAg*; (+) 1-10 wks post-exposure; (+) before liver enzymes rise -acute infxn: *HBcAb IgM* (IgM acute, IgG chronic) -immunity: *HBsAb* (sign of previous infxn or vax so indicates *immunity* & persists *for life*) -infective: *HBeAg*
DUB (dysfunctional uterine bleeding) -def'n -mcc -NBS
-heavy vag bleed in *absence* of structural/organic Dz -mcc: anovulation -NBS: if > 35, need *endometrial biopsy*
nursemaid's elbow -how does child hold elbow -aka -XR? -Tx
-held to body, flexed & pronated -aka subluxed radial head -no XR - will be normal -Tx: reduce via *supination, flexion = SUPER FLEX* (up to humerus) or HYPER PRONATION
Brown-Sequard Syndrome -cause -clin pres
-hemi-section of cord -*i/L loss of MOTOR & PVT* PLUS *c/L loss of PTt* @ *1-2 levels BELOW INJURY* (PTt c/l bc decussates at level of vertebra whereas other 2 decussate across in brain)
occlusion of AV Fistula --> brady -think -pp -Tx
-high output heart failure -pp: arterial flow shifted from L to R --> incr preload --> incr CO --> subsequent HF -surgical banding or ligation; close any unused fistulas (place tunneled catheter)
hymenoptera - includes? comp? Scorpion bite -bite Cx/Sx -dangerous species -Tx
-hymen: bees, wasps, hornets, yellow jackes, ants; comp: anaphylaxis Scorpion -no bite mark (unlike spider) --> CNS Sx (unusual eye movements, hyper-salivation, mm. jerking) -sp: Centruroides (fatal). sting --< *immediate pain/paresthesia at site* -anti-venin available but rare
hypocalcemia -S/S -Cx pe (2) -Tx -how to correct
-i) *Chvostek*: tap facial n. --> i/l facial mm. Cx ii) *Trousseau*: carpopedal spasm (forced wrist flex) upon inflating BP cuff > SBP for 3 mins -Tx: calcium gluconate + Mg -corr Ca = serum Ca + (0.8 x (4 - albumin))
adrenal insufficiency -types & their mcc -cp -Dx -Tx
-i) 1º = Addison's Disease (mc AI, but also 2/2 infxn (Tb)); ii) 2º is d/t chronic CS use -cp: Pt in *refractory shock* (IVF/pressors dont help) w/ *hyper-pigmentation*, anorexia, N/V, ab pn, lethargy, fever, confusion/coma -Dx: labs = *hypoNa, hyperK, hypoglycemia* -Tx: *Hydrocortisone 100mg IV* (has mineralocorticoid fx so better if *e- ab-nl or htn*; ii) Dexamethasone 4 mg IV (better if ACTH stim test w/ cosynotropin up next)
SNAKE BITE -categories of venomous snakes -anti-venom works on? -indications for anti-venom -^BI Dose? Dispo?
-i) CROTALIDS (rattle, mocassin, coppherad) ii) ELAPIDS (coral, cobra, mamba) -*anti-venom* only for *Crotalids, NOT Elapids* (hence why it's called CroFab) -indications: pain/swelling, coag, htn, AMS, fasciculations, paresthesias -BI Tx: 4-6 vials. obs 1 hr, if no improvement, rpt. then ADM bc need 4 vials q6h for 3 doses (18 hrs).
Lyme disease -stages (3) -Tx -Px
-i) early (localized): *target rash* (erythema migrans); ii) early (disseminated): wks-mos later, *neuro Sx* (meningitis, bacterial facial n. palsy) or *cardiac* (AV block) or *MSK* (severe *mono*articular pain); iii) late: arthritis or neuro Sx *mos to yrs later* -Tx: doxy 100 mg BID 2-3 wks (*if preg*, can only give 14d doxy so use *AMOX instead*) -Px: 200 mg doxy PO x 1
HEAT STROKE -2 main criteria -comp -most SN lab finding -2 types
-i) hyperthermia (*> 104º*) & ii) *CNS Sx* (HA, AMS, Sz, coma) -MOF, shock, ARDS, rhabdo (ck CK) -SN lab: *AST* -i) CLASSIC: epidemic, non-exertional, elderly Pt, anhidrosis ii) EXERTIONAL: isolated, healthy young active Pt, hyperhidrosis, *rhabdo & ATN*
traction splint -when to use -benefit
-if femoral shaft fx OK but *c/i in femoral neck fx* -decr mm. spasm, pain & further injury to nn./vv.
back up Tx for hypoglycemia
-if on BB: try *glucagon 1 mg IM* (rmr BB tox where BB interferes w/ gluconeogenesis and glycogenolysis) -hydrocortisone if hx adrenal insuff (COR --> GLU) -octreotide if SU-tox
RABIES -most imp 1st step -best loc for vaccine -sched
-imp: *wound care - wash w/ soap & water* -vax loc: *deltoid* (shoulder mm.); *avoid glutes* bc per *CDC: Ab response here lower bc not made in fat cells* -*VAX (4)*: 1mL IM on day 0, 3, 7, 14 (5th day on day 28 if i-c Pt) *AND...* *Ig (1)*: Infiltrate as much around wound as possible (if no wound, glutes is fine) & place remainder in opposite arm of vaccine; have 7 days to give from 1st vaccine 4 vax, 1 Ig
spinal cord compression 2/2 cancer -seen most where -cp #1 cause of non traumatic reason for tamponade
-in *T spine* -pain 1st, retention --> overflow incontinence is late malignancy (think lung/BRCA)
Hydrofluoric Acid (HF) -used in -mc of death -expected lab abnormalities
-in *glass etching & car wheel cleaning* -death d/t arrhythmia -labs: *hypoK/Ca/Mg*
pretibial myxedema - found in? what is it?
-in Grave's Dz -accum of muco-poly-saccharides --> yellow waxy skin w/ b/l firm dermal nodules/plaques Grave's also has exophthalmos
rule of 50 for hypoglycemia
-infant (<1) gets D10W @ 5 cc/kg (10*5 = 50) -child (1-8) gets D25W @ 2 cc/kg (25*2 = 50) -adult (>8) gets D50W @ 1 cc/kg (50*1 = 50)
tenosynovitis: what is it
-inflm of synovium (*synov*) (fluid-filled sheath surrounding a tendon (*teno*)) --> jt pain, edema
Malignant Hyperthermia -precipitating Rx -pp -cp -Cx Sx -Tx
-inhaled anesthetic, *Sux* -pp: *rare* genetic (AD) d/o of sk mm where excess Ca released from SR --> *sustained Cx + heat prod* -cp: *difficulty ventilating 2/2 chest wall rigidity* -Sx: hyperthermia, rigidity -Tx: *dantrolene* (~NMS bc rigidity (*but NOT* "lead pipe" here);
Brown Recluse Spider Bite -cp -comp -Dx -Tx
-initially mild erythema --> necrosis & *central eschar* form on day 3-4 (pic); sometimes initial can be pain, blister w/ discoloration but not as common -*Loxoscelism*: systemic rxn 1-2 days after bite: F/C, N/V, myalgia, hemolysis, *ARF, DIC*) -Dx: cbc, cmp, coags, UA -Tx: supp, *dapsone* can help prevent local venom fx
mgmt strategies of bladder rupture depend on?
-intra-peritoneal: *surg* - post dome ruptured so urine in GI cavity --> peritonitis -extra-peritoneal: corrected with foley cath (rmr urethra OK here) ^MC (think pelvic fx)
BP mgmt in CVA -ischemic -hemorrhagic -tPA
-ischemic: should *NOT* have BP lowered *unless tPA* candidate in which case *TARGET < 185/110*; -*permissive HTN*: only intervene if *SBP > 220 or DBP > 120* in which case decr *by 25% in 24 hrs* via *nicardipine or labetalol* ^thinking is if you dramatically decr BP, the penumbra (surrounding "at risk" area) can't be hypo-perfused or it will also stroke out -hemorrhagic: LOWER BP ASAP; TARGET SBP 140-160* ^persistently hi BP will cause to bleed out. wont go into hemorrhagic shock but *will herniate*`
hyperK -mcc -if refractory, nBS
-lab error (hemolysis) -NBS: ck Mg -hyperK sharp like *P*i*NS* (peaked, narrow, symmetric) -HATW (~HAWT) sun is *BEAT*ing down on me (Broad base, Elevated J pt, Also symmetric, Tall)
occlusion of a single penetrating branch off a large cerebral a. w/ focal deficit -think? -rFx -prog
-lacunar stroke (lacunar = lake-like) -rFx *#1 = HTN*, smoking, DM -prog good; usually incidentally found so may appear dark on CT bc old
transudate vs exudate -how to best see on XR -appearance, expected labs, mcc
-lat CXR, bad side down -T: clear; low protein & low LDH; mcc CHF, cirrhosis & nephrosis (think overload states) -Ex: bloody, cloudy; high LDH & high protein; infxn (PNA), cancer, PE
lunate vs peri-lunate disloc -best Dx -imp clin ck
-lat XR film (Peri-lunate is Pie-shaped) -ck for median n. assessment Perilunate Dislocation = Lunate stays in place, capitate is displaced Lunate Dislocation = Capitate stays in place, lunate is displaced
lateral vs medial epicondylitis -nicknames for both -which more common -Tx for both
-lateral = tennis; medial = golfers (and pitchers) Lieutenant (LT) and Major (MGr) -lateral most common overuse injury of elbow -rest/NSAID for both
Tibial plateau fracture -mc area -ck this -Tx
-lateral plateau -think lateral: *deep peroneal n.* -Tx: ORIF rmr plateau: area of relatively level high ground (diff from tuberosity)
aortic rupture -mc loc -BI SN Dx test -confirmatory test -best clin PE sign
-loc: descending aorta just distal to subclavian a. -CXR: *widened mediastinum* -CT for confirm -*pulse diff* b/w upper and lower extremities
CIN: Contrast-Induced Nephropathy -what to look for -Dx -rFx -Tx
-look at *GFR, not Cr* -GFR *< 60* -rFx: elderly, DM, htn obviously CKD -Tx: give IVF before & after study; *hold metformin for 48 hrs in DM*
parotitis -close anatomy -mc: viral vs bacterial -2 major systemic Dz that affect this gland
-look for *facial n.* (CN7) -V: *mumps* (self-limited); B: 2/2 *S. aureus* -comp: extra-pulm *Tb & HIV*
jersey finger -problem -looks like? -cause
-loss of flex at DIP -looks like boutonniere -avulsion of FDP (flex digit profundus) from DIP
renal trauma -a/w
-lower rib fx or L1-L2 transverse process fx
inferior shoulder dislocation -aka -clin pres -cause -comp (2)
-luxatio erecta -forearm locked *overhead* -forceful hyper-*AB*duction -N-V compromise + severe rotator cuff injuries
mandible fx -mc and least common areas of fx -S/S -Dx -if also presence of blood think -NBS
-mc *fx: @ condyle* (30%); LC: at coronoid process (2%) -Signs: malocclusion, trismus, chin deviation -Dx: *panoramic radiograph* (need dentist)/OMFS -blood: *open Fx so need Abx* -mental n. anesthesia for analgesia, consult OMFS
epistaxis -mc one -loc -which one bleeds more? -how to differentiate?
-mc: ANTERIOR (90%) -A: Keisselbach's plexus (3 vessels meet here) P: from nasopalatine branch of sphenopalatine a. (10%) -P bleeds more bc involves aa. -diff: place b/l packing anteriorly, *if Pt cont to bleed (runs down oropharynx) --> suspect posterior source*
bugs in necrotizing fasciitis -mc isolates? -types based on bugs -gas gangrene bugs
-mc: MRSA & S pyogenes (aka GAS) -T1: polymicrobial (ie anaerobic & aerobic); T2: *GAS*; T3: clostridial myonecrosis aka *gas gangrene* -GG in trauma: C. perfringens; GG spont: C. septicum
extra-pulm Tb -mc site -mc neuro Dz -skeletal site
-mc: painless cervical LN -neuro: meningitis -Pott'z Dz in spine
hth (hypothyroidism) -mcc (4) -S/S -Tx
-mcc: Rx (over-Tx of Grave's vs A/E of Li vs amio), diet (iodine def), AI attack against thyroid (*Hashimoto*) -S/S: *slowed mentation* (AMS, psychosis); *cardio* (CHF, brady, pericardial effusion); *myxedema* (puffy face, ext) -Tx: levothyroxine (synthetic TH)
septic arthritis -mcc -how often Cx (+)? -spread -T/F (-) jt Cx can r/o septic arthritis ex: fluid shows 75K wbc but (-) gram stain with crystals - NBS
-mcc: S. aureus -Cx (+) only 50% of time -spread by hematogenous > direct inoculation -False - does not rule out ex: Tx w/ Abx!
food poison/AGE match -mcc foodborn Dz -a/w undercooked meat left out too long in buffet -a/w fried rice -a/w potato salad & cream filled pastries -a/w heat labile neurotoxin
-mcc: S. aureus -meat in buffet: C. perfringens -fried rice: B. cereus -potato salad & cream filled pastries: S. aureus -heat labile neurotoxin: Botulism
otitis externa in diabetic - think -mcc -pe -Tx -NBS
-mcc: again Pseudomonas -pe: pain out of proportion w/ CN 7 dysfxn (facial n.) -Tx: *cipro 6-8 wks* -admit if bad, *ENT f/u in 12-24 hrs* no matter what even if looks OK bc *potentially fatal*
sympathomimetic toxicity -caused by -Sx -how to distinguish
-mcc: cocaine, amphetamines, caffeine -HTN, hyperthermia, tachy, tachypnea, mydriasis (pupil dilation), diaphoresis (*ALL UP*) -Anticholinergic: *HYPO*active BS; *NO* Sweating *SNS*: *HYPER*active VS; *S*weats for *S*NS
hyperCa -mcc -saying to help rmr -cp -EKG Cx -Tx
-mcc: hyperparathyroidism -stones, GI groans, bones, mental moans -cp: kidney stones, ab pain w/ N/V, bone pain/fx, AMS -EKG: shortened QT -Tx: i) IVF; ii) *calcitonin* (opposite of PTH); iii) *LO*op diuretics (furosemide *LO*wers Ca); iv) HD prn
hypocalcemia -mcc -ekg cx -S/S
-mcc: hypoPTH (2/2 thyroidectomy), ARF, vit D def, *pancreatitis* -EKG: prolonged QT interval -S/S: tetany, paresthesias, cramps to spasm, Sz
otitis externa -mcc -rFx -Tx
-mcc: i) *pseudomonas*; ii) staph epidermidis -rFx: *swimming*, qtip causing abrasion, hearing aids/headphomes -topical Abx w/ CS (cipro-dex) or cortisporin (HC + neomycin) - use Suspenion, NOT SOL'N (in case of perf)
tuba-ovarian abscess (TOA) -mcc -Tx
-mcc: polymicrobial -Tx: amp + gent + clinda
PROM (premature rupture of membranes) -mcc -NBS -SN vs SP test
-mcc: too many digital pelvic exams -speculum exam & give Abx (prevent chorio) -*SN: N*itrazine (+ is blue color seen after exposure to fluid); *SP: Ferning* (amniotic fluid dries on slide) ^rmr nl vag pH in preg: 3.5-6; *amniotic pH > 7 (basic)*
pericarditis -mcc -cp -PE sign -EKG Cx (3) -Tx
-mcc: viral -cp: pleuritic cp *relieved by sitting up & forward, worse while supine* -PE: pericardial friction rub -EKG Cx (3): diffuse STE, diffuse PR depression, *spodick sign* (down-sloping T-P segment) -Tx: NSAID, Colchicine
clavicular fx -which 1/3 mc involved -Tx -indications for ortho referral -comp
-middle third -sling + ROM exercises -displaced fx, N-V compromise, *skin tenting* (implies sig displacement + impending open fx) -adhesive capsulitis (frozen shoulder) if no ROM exercise
myxedema coma -misnomer -cp -Dx -Tx strategy
-misnomer: *NOT* edematous or comatose -cp: *elderly F in winter that's cold & confused* w/ dry skin, *prolonged relaxation phase of DTR*, non-pitting periorbital edema -Dx: hth labs + *hypoNa*, hypoglycemia, hypothermia & *hyperlipidemia* -Tx: *T3 vs T4* (rmr T3 bio active form so --> arrhythmia whereas T4 has lower risk of tox d/t delay in conversion) i) elderly/cardiac Pt: T4; ii) ill young Pt: T3 -*ADD CS*: hydrocortisone 100 mg IV (*adrenal insuff accompanies myxedema coma*)
preg F with new murmur & pulmonary edema -think? -cp -murmur Cx -EKG Cx
-mitral stenosis -DOE, orthopnea/PND -loud S1, *opening snap* (OS in MS/MicroSoft) -EKG: AF, LA enlarged
CCB OD -most dangerous Rx -cp -1LTx? -2LTx? MOA?
-most dangerous: *Verapamil & Diltiazem (non-DHP*) - so incr fx on heart, weak vasodilators -cp: ~ BB tox = brady, decreased Cx, htn w/ *HYPER*glycemia -1LTx: *Calcium* (give what's blocked) -2LTx: *hi dose insulin & GLU*; MOA: <3 usu prefers FA as energy source *but under stress (ie htn shock), <3 prefers GLU*; also CCB blocks insulin release
mcc of lower GI bleed by age: neonate, infant, PEDS
-neonate: anal fissure 1st, then volvulus, NEC, then milk allergy -infant: *intussusception 1st*, meckel's, fissure, other -child: anal fissure 1st, *HSP*, HUS, other
SLE -mc neuro Sx -Dx: SN vs SP -variant with facial manifestations -med advice on preg -Rx most a/w drug-induced lupus -Tx -T/F: most Pt with lupus anti-coagulant dont have lupus
-neuro Sz -SN: A*N*A; SP: Anti-Smith Ab -variant: *discoid lupus*: raised scaly plaques on face worse when in sun -F should not get preg until remission for at least 6 mos -Rx: procainamide & hydralazine -Tx: PO *CS + MTX* (esp if multi-organ involvement) -T: and most with SLE dont have lupus anti-coagulant
non-displaced ulnar shaft fx -aka -imp clin pt - check for this
-nightstick fx -check for RADIAL N. (ulnar n. is rarely involved in forearm fx)
Lithium toxicity -initial Tx -make sure to ck -how often to ck -definitive Tx
-no AC/charcoal bc CHEC M*L* - start w/ *WBI* (PEG/GoLytely) if acute - 0.5-2Lqh until rectal d/c clear -ck *[Na]*: hyperNa can exacerbate neurotoxicity -ck Li q4h -*HD* (I-STUMB*L*ED): *Li > 5, Li > 4 if Cr > 2, decr LOC or Sz* - keep HD going till level < 1 for 8 hrs
uremic pericarditis -cp -why
-no EKG changes, no chest pain -instead of inflm cells deposited in pericardium, it's *fibrin deposition* so no immune response
cardiac transplant -what to know -if Pt brady - NBS
-no autonomic innervation in heart so HR 90 which won't change with stimulation. EKG has two p-waves (donor P appear normal, native P small amplitude) -won't change w/ atropine, use *isoproterenol* (non-sel β agonist; isopropylamine analog of Epi used for brady)
ARDS -aka -Dx criteria (4) -eqn -mortality rate -vent settings
-non-cardiogenic pulmonary edema -Dx: acute onset, hypoxia, PCWP *(wedge P) < 18* (ie NL LA P = NL vent fxn since *non*-cardiogenic), *diffuse b/l infiltrates/edema*; -eqn: PaO2/FiO2 < 300 (lower the worse it is) -rate: *40%* -vent: *low TV + low plateau P* (rmr changes in peak P less worrisome than changes in plateau)
pulmonary contusion -timeline -if suspected, NBS -Tx
-not seen on initial XR bc develop *w/in first 24 hrs* & resolve by *1 wk* -put in *dependent position: good lung down* ^optimizes V/Q matching by perfusing good, bottom lung and result in best oxygenation -pain control, pulm toilet, *restrict fluids* (will worsen edema) - *low threshold to intubate*
aspiration PNA -Tx?
-only Tx if *ill appearing* bc most cases do not req empiric Abx & chemical vs bacterial aspiration appear similarly in the beginning. Tx = *Zosyn* or fluoroquinolone
Tamiflu -aka -MOA -routes -when should it be started -other options
-ostelamivir -MOA: neuraminidase inh -routes: oseltamivir is PO, zanamivir is inhaled (c/i in asthma) -stared w/in 48 hrs of sx onset to be effective in decr duration -amantadine only good for influenza A
otitis media -pe: most SN vs most SP -mcc -Tx -mc comp
-pe: SN = impaired TM mobility; SP: bulging TM -mcc: *Strep pneumo* -Tx: *Abx IFF* i) 6 mos+ w/ severe otalgia + fever 102º; ii) 6-23 mos. w/ non-severe but *bilateral* (= *AMOX*) -comp: *hearing loss*
Herald patch -think -what is it -Tx
-pityriasis rosea -single salmon-colored lesion on trunk -Tx: *anti-histamines*
elbow dislocation -mc type -imp to check
-posterior mc -*brachial a./ulnar n.* (ie NOT MEDIAN)(BU/BOO! dont be scared - brachial a. rides anterior humerus all the way down; ulnar n under medial epicondyle *w/in the elbow itself*) RMR THIS IS AT THE ELBOW, NOT HUMERUS
Anterior cord syndrome -pathophys -loc of injury -clin pres -distingiushing features
-pp: *flexion* injury --> anterior spinal a. infarct -*anterior* CST + *Antero*lateral System -*paraplegia/motor paralysis + loss of PTt - BELOW level of lesion* -*preservation of PVT* (from DCML, Position, Vibration Light/Fine Touch)
MG -pp -cp -a/w
-pp: AI attack against ACh-R's -cp: *ptosis*, mm. wknss (*worse w/ repetitive use*) -thymoma
Carbon Monoxide (CO) poisoning -pp -1LTx -rFx -cp -mcc death
-pp: CO *binds to Hb w/ incr affinity* > O2 -1LTx: *HFNC*; definitive *HBO* -rFx: *smoke inhalation*, heating systems -cp: vague (*HA*, nausea, dizzy, confused, *cherry red* lips/skin) -mcc death: *MI*
horner's syndrome -pp -cp -diff from CN3 palsy -Dx -if acute onset, NBS
-pp: Sympathetic trunk/cervical ganglion damage -cp: *ptosis, miosis, anhidrosis* -vs CN3, ptosis much more subtle here bc CN3 spared -Dx: *topical cocaine* - apply to both eyes, if NL both should dilate but here affected side *won't dilate* -acute: get CT brain + *CTA (r/o carotid a. dsxn)*
BPPV -pp -Dx vs Tx
-pp: clumped otholiths --> impair endo-lympahtic flow --> canolithiasis (calcium debris) form in posterior semicircular canal -*Dx* = *D*i*x*-Hallpike; Tx = Epley
LEMS -pp -cp -distinguishing Sx from MG -a/w -Tx
-pp: failure of release of ACh from motor neuron axon -cp: wknss of *prox mm (thighs, hips)* that *improves w/ repetitive use* + dry mouth, ed; -diff from MG: *less eye Sx* -a/w SmCLC -Tx: IVIg, plasmapharesis (same as MG)
Cyanide toxicity -pp -Cx feature -timeline -severe Sx -Tx
-pp: inh Mt cytochrome complex --> anaerobic metabolism --> *LA builds up --> HAGMA* (met-acid) -"*bitter almond odor*" -time: depends on exposure: inhalation is immediate, dermal is delayed (hrs) -severe Sx = Parkinsonism, neuro sequelae -Tx: hydroxy*C*obalami*N* (for *CN*) + *sodium thiosulfate* > sodium & amyl nitrite (kit out of prod)
Von Willebrand Disease (vWDz) -pp -Tx
-pp: missing vWFx -Tx: ddAVP (*Desmopressin*) = synth vasopressin/ADH = *incr plasma Fx 8 & vWFx*
Rhabdomyolysis -pp -Dx -assoc BMP -Tx
-pp: mm. necrosis 2/2 trauma, crush, burn, heat stroke --> CK moves into bloodstream -CPK elevated > 5x NL (don't need myoglobinuria, only 50% of time is (+) w/o hematuria) -BMP: hyperK, hyperP, hypoCa ~ Tumor Lysis -Tx: IVF to *target UOP at 200 cc/hr (3 ml/kg/hr)*
tick paralysis -pp -cp -diff from GBS -Tx
-pp: release neurotoxin that decr ACh release @ NMJ ~ botulism/LEMS -rapid *ascending paralysis* with loss of DTR's -GBS: tick also has *ataxia* -Tx: remove tick
carcinoid syndrome -pp -cp -BI Dx -comp -Tx
-pp: serotonin-secreting tumor -S/S: *flushing, secretory diarrhea*, ab pm -BI Dx: *24 hr urine for 5-HT metabolites* -50% of Pt get restrictive CMP (5-HT induced fibrosis); *carcinoid crisis* excess 5HT release --> death -Tx: octreotide
GTD (gestational trophoblastic disease) -pp -rFx -a/w
-pp: serum hCG very hi (> IUP levels) w/ uterine size > gestational age -rFx: extremes of age (< 20, > 35), prev GTD -a/w hyperemesis gravidarum
SICKLE CELL ANEMIA -pp -mcc -1st cp as infant -mcc death -preventative Rx -Dx -Tx -mcc of osteo -comp; NBS
-pp: sluding of sickled RBC's --> obstruction --> ischemic pain -mcc: dehyd, cold weather, infxn, hi altitude -cp: *dactylitis* of hands/feet at 6-9 mos -death: acute chest syndrome = new infiltrate on CXR -prevent w/ *hydroxyurea* -Dx: retic ct (should be hi) -Tx: *exchange transfusion (if severe)* -osteo: *Salmonella* > S. aureus -splenic infarct --> vaccines against encapsulated bugs (*SHiN* = Strep pneumo, Hib, Neisseria); also priapism
epididymitis causes in different populations -pre-pubertal boys -sex active M < 35 -MSM (men sex w/ men, esp anal) -M > 35
-pre pubescent: think structural abnormalities or *Mycoplasma pneumoniae or adenovirus* - < 35 M = GC/C -MSM: E. coli or pseudomonas - > 35: bacteriuria 2/2 BPH, think Psuedomon (Tx: fluoro)
Pre-Eclampsia -def'n -rFx -cp -comp -Tx
-preg > 20 wks w/ *proteinuria, HTN, edema (PRE, PHE)* -rFx: pre-existing HTN/DM/obesity, extreme age, primagravid (*or 1st preg w/ new partner!*), or *very short (<2 yrs) or very long (> 10 yrs) time in b/w preg's* -cp: HA, vision changes, abdominal pain -comp: incr risk of Pre-E in future, *risk for CAD/DM* -Tx: bedrest, BP control (*HLN: H*ydralazine, *L*abetalol, *N*ifedipine - all class *C*) & delivery (best)
Meralgia Paresthetica -clin pres -problem -Tx
-preg F with lateral thigh burning type pain -lateral femoral cutaneous nerve compression -NSAID, wt loss, CS injxn
why Tx strep so aggressively? -think? -criteria -timeline
-prevent *Rheumatic fever* -JONES: Joints, ♡ - myocarditis, Nodules SubQ, Erythema marginatum, Sydenham chorea -un-Tx'd strep --> rheumatic fever in 2-4 weeks; takes 10-20 years to develop rheumatic heart
HIT -how to prevent -Tx -c/i -when can warfarin be started? -T/F: Pt w/ HIT can never get heparin again in life
-prevent: don't use heparin for > 5d. use *LMWH* if nec. -Tx: *Stop heparin*, start NOAC. -c/i: *PLT transfusion dangerous bc can cause thrombosis* so do w/ caution -start warfarin when PLT > 150K -F: only if nec can get (eg short dose before CABG)
stages of repair? when is 3º best?
-primary intention: wound closure as normal -secondary intention: wound allowed to *granulate & close naturally* (ie *NO lac repair* --> significant scar) -tertiary intention: aka *delayed primary closure* - clean wound now, wait 3-5 days, then close (in 3º, wait 3d) ^3º best if *contaminated* OR if 2/2 *animal bite* ^^logic is let body do the clean up - by 3d Macrophage activated and phagocytosis underway
peritoneal dialysis -benefit -mc comp ^cp -Tx
-pro: no hep req'd (to keep line open), less comp -*peritonitis*: fever w/ ab pain; fluid w/ WBC > 100 (w/ PMNs); other comp = ab wall hernia -Tx: intra-peritoneal Abx (if septic, IV good)
maisonneuve fx -what is it -seen w/? -cause -PE Dx test
-proximal fibular fx -medial malleolus fx (*across* from each other) -eversion injury causing medial malleolus pain -squeeze the calf, if tender, get tib/fib XR too
indications for dialysis for ASA tox how often should levels be checked
-pulm edema (from flooding the Pt from resusc) -renal failure (they can't diurese via urinary alk) -unstable VS -neuro Sx (Sz, coma) -levels *> 120* (> 100 if >6 hrs post ingestion) ck level q2h until they are declining
varicella PNA -rFx -CXR Cx -Tx
-rFx: preg, i-c, COPD, smoking, advanced age -CXR: *mult small nodules* thru both lung fields -Tx: *IV* acyclovir (not PO)
PID -rFx -Cx pe finding -comp -Tx -dispo
-rFx: vag delivery by *untrained person*, smoking, IUD, young age (*old age is not one*) -pe: (+) CMT -comp: ectopic, infertility, FHC (perihepatitis) -PID Tx: rocephin/azithro *OR* rocephin/doxy +/- flagyl -admit if preg, failed OP Tx, or TOA (abscess)
wrist drop -nerve involve -Tx -prog
-radial n. for w*R*ist drop -splint in extension -can take days to years to resolve
SLR -how to do SLR for sciatica -other Dx's -superior alternative
-raise to 30-70º if radicular pain elicited *PAST the knee* = (+) for herniated disc w/ n. root compression -if <30º with radicular pain past knee, think abscess, tumor, spondylolisthesis -*crossed SLR*: same thing on *c/l leg* (also has high SN but THIS ONE HAS *HI SP*)
pancreatic injury in trauma -mcc -Dx helpful?
-rapid *deceleration* injury: pancreas displaced against vertebral column -no. initial labs/imaging normal
emphysematous cholecystitis -what is it -mcc -rFx -NBS
-rare variant whose US shows *air in GB wall* -bacteria: E. coli, Clostridium, B. fragilis -rFx: DM, man -emergent surg bc risk of perf 2/2 gallbladder gangrene
bacterial tracheitis -what is it -cp -mcc -Dx -Tx
-rare, fatal superimposed bacterial infxn in PEDS of subglottic trachea --> upper airway obstruction -cp: PEDS Pt with viral pharyngitis with super imposed bacterial infxn --> *thick purulent exudate + upper airway obst* (stridor, cough, resp distress) -mcc: S. aureus -XR: steeple sign, same as croup (this is bact croup) + *bronch* to look for *pseudo-membranous exudates* -Tx: airway mgmt, Abx b-s, *bronch*
Tb types & what to expect
-reactivation Tb: CXR shows apical posterior lung involvement (pic) -miliary: hematogenous dissemination -active Tb: CXR = infiltrates, *cavitary lesion w/ hilar adenopathy* (prev)
punch to face with vision loss and protruding eye/proptosis -think? -NBS? -best DX imaging? -comp?
-retrobulbar hemorrhage -lateral canthotomy & call ophtho -CT w/o of face & orbits -compartment syndrome & CRAO
NAC -MOA -admin w/ their A/E -which admin preferred
-rmr all your glutathione are used up so NAC is a *glutathione-like substrate which re-binds NAPQI* -PO can cause N/V; IV can cause anaphylaxis -*IV* > PO bc if you vomit in PO, have to rpt dose. if you take > 8 hrs to drink, window is lost. *& if evidence of liver failure, only IV helps*
Sialolithiasis -what is it -cp -Dx -mc involved gland -rFx -Tx -comp
-salivary duct stone (made of calcium) -cp: pain at site of gland, worse w/ eating -Dx: pe best but if can't see - CT non-con -mc: *submandibular* (wharton's duct) -rFx: smoking, Rx (anti-cholinergics (benadryl, amitryptiline), diuretics), dehyd -Tx: hydrate, use heat, massage gland/milk duct, *sialogogues (lemon drops)* + d/c meds if causing it -comp: *sialadenitis = stone + fever/pus* from duct = need anti-staph *Abx (dicloxacillin, keflex)*
TCA overdose -2 main A/E -A/E correspond to? -Tx
-seizures & VT/VF -if QRS > 100, think Sz; if > 160 think VT -Tx: *sodium bicarb until QRS normal*; hypervent (alkalotic state has bicarb effect); lidocaine 3LTx
acute severe massive cyanotic u/l L/E -think? -pp -Tx -comp
-severe DVT: *phlegmasia cerulea dolens* -pp: DVT in large ileofemoral clot -Tx: possible tPA -comp: r/o compartment
aspiration PNA -severity depends upon -Cx CXR -mcc
-severity depends on aspirate's: volume, pH, particle composition and a/w bacterial contamination -CXR depends on position Pt was in during aspiration: i) supine: upper lobe posterior segment or lower lobe superior segments ii) *standing: RLL* or b/l -mcc: S. pneumo (if HCAP Tx pseudomonas), if alcoholic w/ poor dentition - Tx anaerobes
Hutchinson sign -indicates what -Dx
-shingles on nose so think *herpes zoster ophthalmicus* -Dx: Pseudodendrite on slit lamp
elderly man with hx chronic constipation p/w slowly prog ab pain, nausea, vomit several days after onset of pain - think? -comp -Tx -recurrence?
-sigmoid volvulus -comp: bowel necrosis, gangrene, perf, sepsis, death -1LTx: *flexible sigmoidoscopy* (if no perf, otherwise ex-lap) *bowel decompression w/ NGT & rectal tube* -recur 50% if no surg done
hypertensive emergency -def'n -goal
-signs of end organ dmg (wt*HECK*: *H*eart (ACS, CHF, dsxn), *E*yes, *C*NS (Encephalopathy), Kidney (ARF)) -Tx: *decr BP by 25% in 24 hrs*
necrotizing fasciitis (nec fasc) -clin pres -PE sign earliest finding -BI Dx test -MA Dx test
-soft tissue swelling & pain 2/2 trauma -pain *out of proportion* -XR: subQ air/emphysema (gas prod bug) -MA: MRI
PE -mc source -mc EKG -mc CXR -massive PE Tx
-source: prox leg DVT or *pelvic v. thromboses* -EKG: tachy #1 (then RBBB, RAD, S1Q3T3) -CXR: pleural effusion -tPA: *100 mg over 2 hrs*
priapism following spinal cord injury indicates -what type of shock -prog? -type of priapism
-spinal shock -self-limited, req's no specific Tx -*hi-flow (non-ischemic)* ie blood w/in corpus is *arterial* (vv. is worse bc it cannot drain)
CUTANEOUS ANTHRAX -spread: -stages of changes -Tx
-spread: cutaneous *spread by skin 2 skin* -small painless papule --> enlarged central vesicle --> necrotic ulcer w/ black eschar -doxy
INHALED ANTHRAX -spread: -Dx: XR expected changes -Tx:
-spread: inhaled is *NOT* contagious -CXR: widened mediastinum + hilar adenopathy -Tx: doxy
Acute Radiation Syndrome -stages -what to do in pre-hospital -imp hospital consideration -tissues targeted
-stages: Prodromal (GI Sx), latent (Sx-free), illness, death or recovery -pre: remove clothes, evacuate scene, wash w/ soap & water -hosp: Pt needs to come from separate entrance that has a closed ventilation & drainage system -tissue w/ hi rates of cell turnover (*hematopoietic*)
ER burn mgmt how to monitor efficacy of your fluid resusc?
-superficial: NSAID & topical aloe -2º: 1st topical Abx, 2nd non-adherent Xeroform gauze, 3rd layer of dry gauze, 4th elastic gauze (Kerlix) -Tx to burn unit: dry sterile dressings only -fluid: monitor *UOP*: should be 0.5 cc/kg/hr HOURLY
vertebro-basilar artery stroke -pp -Dx challenge -cp -2 main types
-supplies brainstem/cerebellum -cerebellum not captured on CT so needs *MRI* -cp: crossed deficits so i/l CN palsy, c/l hemiplegia + vertigo, nystagmus, ataxia -2 types: locked in syndrome (basilar a.) or wallenberg's
Sarcoid -what is it -transmission -Dx -staging? mc non lung site? -Tx?
-systemic granulomatous Dz where non-caseating granulomas deposit all over body -trans: *not infectious* -*CXR*: b/l hilar adenopathy + infiltrates; *LABS: hyperCa, hi ACE, anemia* -staging based on ^CXR; non lung: skin -Tx: *CS*
rotator cuff tear -acute clin pres -cause -Tx -what to look for on XR
-tearing sensation in shoulder + poor localized rads pain down arm -FOOSH or w/ shoulder disloc -Tx: sling + refer to ortho for OP F/U -decr AH (acromio-humeral) distance
Toxic Shock Syndrome -cp -mcc -Tx
-teenage girl using *tampons* (not pads) w/ hi fever, NVD, rapid sunburn like rash diffusely w/ desquamation (on palms & soles) -S. aureus but BCx *never (+)* -Tx: remove, Abx
Wernicke's encephalopathy -cause -common Pt -Sx -Tx -a/w
-thiamine (vitamine B1) deficiency -alcoholic, malnourished -triad: *PAC* (nystagmus ophthalmo*P*legia, *A*taxia, *C*onfusion/encephalopathy) -Tx: thiamine replacement -a/w Korsakoff (PAC: Psychosis, Amnesia, Confabulation)
E coli diarrhea 0157:H7 -incubation period -comp -EHEC a/w -Tx -prog
-time from exposure to sx: 3-4d -comp: HUS - anemia, renal failure, thrombocytopenia -undercooked hamburger, petting zoos -Tx: *avoid Abx* (promote toxin release) bc.. -no systemic signs (fever) bc organism *NOT invasive BUT prod toxin which are* (hence no Abx)
rash matching -rash starts on head and spreads down -more benign form of ^ -fever RESOLVES, then rash on body -URI w/ fever, slapped cheek rash starts in middle -Vesicles on erythematous base on buccal mucosa, then limbs -palpable rash on butt -like hand food mouth but only on mouth -ulcer on lip -umbilicated lesions -Forschheimer spots -Koplik spots -strawberry tongue (2) -eradicated clear fluid-filled vesicles to pustules -pruritic generalized vesicular exanthem
-top down rash: measles (rubeola) -more b9 form: rubella (german measles, 3d measles) -defervescence: ROSEOLA -slapped cheek: Erythema Infectiosum/Fifth Dz -vesicles mouth: HFM dz 2/2 coxsackie A -butt: HSP (hematuria, skin/palpable purpura, pain in GI/jts) -HFM without hand or foot: herpangina -ulcer: herpes 2/2 HSV1 -umbilicated: Molluscum contagiosum -F spots: rubella = petechiae on hard/soft palate -Koplik = measles (rubeola) -strawberry: if w/ sandpaper rash = scarlet fever 2/2 GAS; if with CRASH then Kawasaki -eradicated vesicles: smallpox -pruritic: chickenpox 2/2 VZV; later zoster (Shingles)
APAP (acetaminophen) -toxic dose -MOA of OD -predisposing Fx to injury
-tox dose: *150 mg/kg* in single ingestion -MOA: metabolism shifts to CYP450 in liver where *glutathione* stores (which normally binds toxic metabolic *NAPQI*) are used up & *NAPQI* binds to cell proteins in the liver which leads to cell death -predisposition: chronic EtOH abuse
-toxic EtOH that doesnt need acute mgmt? labs? -oil of wintergreen think? a/w? -c/i in scabies & preg -when is neonatal jaundice the worst? -avulsed tooth mgmt?
-toxic etoh: isopropyl alcohol needs no Tx; (+ OG, - AG) -oil of wintergreen = severe ASA toxicity is a/w hypoglycemia (ASA impair gluconeogenesis) -c/i: lindane -jaundice worse if in *first 24 hrs*; NL is *after day 1* -tooth: put in milk or salt solution (hank's) but re-implant w/ dentist ASAP
The highest risk of HIV transmission is during what stage cp of acute phase 3 malignancies defined as AIDS defining
-transmission highest during acute stage (2nd is chronic - once Ab's develop; 3rd is AIDS when defining illness comes on): viral titers hi and most Pt unaware of Dx so people less careful -cp: exposure --> 10-14d later w/ fever, HA, malaise -3 cancers: invasive cervical CA, Kaposi sarcoma. lymphoma
EPA (Epidural Abscess) -Sx -mcc -rFx -BI vs MA Dx -Tx
-triad: fever, back pain, neuro deficits -bug: S. aureus -epidural cath, DM, EtOH abuse, HIV, IVDU -BI: ESR/CRP. if hi go to MA: MRI (order anyway if suspicion is high) - do *MRI of entire spine* -Tx: vanco *before MRI*
Opioid toxicity -triad of sx -comp -Tx
-triad: resp depression, miosis, sedated -comp: ARDS 2/2 resp depression -Tx: naloxone (narcan)
Majocchi granuloma (Tinea Corporis) -mcc -pp -Tx
-tricophyton rubrum -dermatophyte (fungal skin infxn) on epidermis that can enter dermis after trauma to skin (shaving) --> subQ nodule vs abscess -Tx: PO anti-fungals
Tic doloreux -aka -cp -Tx -dispo
-trigeminal neuralgia -sharp, electric shocks in trigeminal nerve distribution (can affect *any branch, even mult*) w/ spont remission -carbamazepine/Tegretol -f/u with neuro for OP MRI (r/o underlying *MS or intra-cranial lesion*)
cluster HA -clin pres -distinguishing features from migraine -Cx Sx -Tx
-u/l HA lasting 30-90 (sometimes 180) mins that appear in "clusters", daily at the same time over several weeks -no prodrome/aura, no N/V or photophobia, acute onset -ptosis, miosis, *lacrimation, rhinorrhea*, conjuntival injxn -*100% O2 NRBM for 15 mins* + triptans
cardiac stent thrombosis -timeline -rFx -Tx
-up to 1 yr -rFx: #1 non-compliance with anti PLT, cocaine (activates PLT) -Tx: PCI
fight bite -what is it -imp step - why? -most common jt affected -comp if no Tx
-usu an open fx -*IV Abx* bc hi (P) for infxn since ext tendon + MCP jt avascular (so limited ability to combat infxn) -*3rd MCP jt* of *dominant* (ie punching) hand -no Tx --> tenosynovitis
vitamin A irregularity - give Sx: -vit A def -vit A excess -vit B3 (niacin) excess -vitamin B6 (pyridoxine) excess -vitamin D excess
-vit A def: *night blindness* -vit A excess: hepato-toxic, hypercalcemic, ICH -vit B3 (niacin) excess: flushing -vitamin B6 (pyridoxine) incr: *peripheral neuropathy* -vitamin D excess: *hypercalcemia*
INTUSSUSCEPTION -late findings -Dx: BI vs MA -prog
-vomiting that was initially non-bilious becomes *bilious vomiting + currant jelly stool* -Dx: XR not helpful 50% of time; *BI = US: target sign* but not always; *MA = air/contrast enema - also Tx* -hi recurrence, may need surg
ACHILLES TENDON RUPTURE -clin pres -PE Dx test -Tx
-weekend warrior (ie recreational athlete/someone who occasionally exerts) with sudden burst of dorsi- or plantarflexion while trying to jump or run with sudden "pop" heard w/ *pain in posterior ankle* -palpable defect; *Thompson test*: compress calf, look for plantar flexion (absence of flex = (+)) -Tx: splint in *equine* position (bring up to gradually dorsiflex in neutral position as if horse rider); not always surg
Traveler's Diarrhea -cp -NBS -mgmt
-well appearing adult recently travelled w/ 1 wk hx of cramps and watery diarrhea -PO hydrate & discharge w/ Sx-care -*ETEC #1 (mcc) --> single dose PO cipro* UNLESS if *kids, preg, from SE Asia --> single dose azithro*
meniscal tear -clin pres -largest/worst -assoc w/
-while moving: clicking, catching, jt locking -bucket handle -a/w ACL tear (can be unstable, cause ongoing pain)
lichen planus -cp -a/w -Tx
-white *lace-like* pattern of pruritic papules -a/w *hepC* -Tx: CS (topical or intra-lesional)
Leukoplakia -what is it -cp -how to diff from candida
-white patch/plaque on oral mucosa that is a *precancerous lesion* -cp: *smokeless tobacco user* w/ buccal white plaque -diff: *CANNOT BE SCRAPED OFF* (*Can*dida *Can*)
Pertussis -aka -stages of Dz -when sputum Cx useful? -Tx
-whooping cough -stages (3): i) catarrhal (URI Sx 1-2 wks); ii) Paroxysmal: cough (1 mo); iii) Convalescent: chronic intermittent cough for mos. -*C*x only in *C*atarrhal phase -Tx: *azithro (macrolides)*; most improve 3-4 wks *w/o* Abx but given anyway bc *hi infectivity, not to decr duration of sx - give to all close contacs*
LBBB Cx
-wide QRS -V1-2 deep S wave -V5-6 notched R wave
TCA overdose -EKG triad (3)
-wide, dominant R wave with *secondary terminal *R' wave (> 3 mm) in aVR* -*wide QRS 2/2 RBBB* (delayed RV activation from inter-ventricular conduction delays bc R bundle is more sensitive to blockade --> *RAD*) -prolonged QTc
open book fracture -aka -cause -ER NBS -Tx
-widened pubic symphysis -AP compression ie crush injury (think feet on a dashboard in MVA) -pelvic binder or wrap bed sheet over *greater trochanter (widest portion of femur)* -*IR* for angiography w/ embolization + ORIF
THYROID STORM -how to differentiate from regular hyperthyroidism -cp
-you cannot - it is a clinical dx. not related to magnitude of excess TH -cp: CNS dysfxn, *VERY HI* fever (40-41º = 104-106º), tachy (out of proportion to fever)
lesser trochanter fracture -clin pres -cause
-young adult that can ambulate but *CANT* lift leg from floor in seated position -forceful contraction of iliopsoas
staff needed for procedural sedation
1 provider + 1 nurse
per ATLS, criteria for referral to burn unit (5)
1) *3º/Full* thickness burn of *ANY* size 2) *2º/Partial* thickness *> 10% BSA* 3) *Infant (ie < 1)* with any burn 4) burns to face/ears, genitals, hands/feet, joints 5) Inhalation injuries (singed nose hairs, soot in mouth) 123 - 1 y/o, 2º 10%, any 3º
Disseminated gonococcal infection (DGI) - 2 types -Dx? -mcc -Tx?
1) *DGI: D*ermatitis, *G*un metal gray petechial macules (can become vesicles), *I*nflm (polyarthralgia, tenosynovitis) 2) purulent arthritis *w/o dermatitis* -cal also present as Infective Endocarditis = FROM JANE -Dx: Cx synovium, rectum, skin, urethra -mcc: Neisseria gonorrhea (if Pt < 30) -Tx: 1 g rocephin IV/IM q24h until sx improve
Transfusion Rxn & NBS (4)
1) *Hemolytic*: incorrect crossmatch --> fever, cp, htn -*NBS: stop• transfusion & rpt *CBC (r/o hemolysis)* 2) *Febrile: mc form* = Pt has Ab's to donor WBC's --> short lived fever. *NBS* = give anti-pyretics 3) *Allergic*: urticaria, pruritus, anaphylaxis; NBS: Tx 4) *TRALI*: resp distress/*ARDS* lasts 4d; NBS: stop; O2
first step of ACLS of coding preg woman (even before CPR)
1) *displace uterus*: have Pt lie on her *left side* (in left lateral decubitus, rmr IVC on R so lying on L frees up venous drainage back to <3 & prevents htn) 2) CPR
tamponade detected - NBS for Tx
1) *give IVF* (preload dependent as effusion collapses on RV hence diastolic collapse) 2) pericardiocentesis
2 BB with unique Tx? why/MOA?
1) *propranolol* --> *widened QRS* --> needs *sodium bicarb* (bc it's also *Na channel blocker*); particularly *CNS toxic* bc lipophilic so crosses BBB --> coma, Sz 2) *sotalol* --> *prolonged QT* --> ck for *Torsades* -also has long t-1/2 both w/ *sodium channel blockade* properties - lethal as they prolong QT/widen QRS
Indications for deferoxamine for Iron Toxicity (5)
1) *severe Sx* (AMS, unstable VS, GI hmrg, intractable N/V) 2) HAGMA 3) serum *Fe level > 500* 4) serum *Fe level > TIBC* 5) significant # of pills seen on KUB
Iron overdose: stages of toxicity by time after ingestion
1) 30 mins - 6 hrs: *GI* phase (N/V/D) 2) 6-24 hrs: *latent phase* (seeming resolution of Sx) 3) 12-24 hrs: *met-acid, shock, end organ failure, coma* 4) 2-3 *days: hepatic failure* 5) 3-6 *wks: SBO*
2 types of 1st metacarpal base fx
1) Bennet: intra-articular (easy *B*reezy) 2) Rolando: comminuted intra-articular (Roland is Complex)
infectious mono - 2 types? mc? of the mc one, cp, Cx pe, comp, NBS, Tx
1) CMV mono - fever, systemic sx, *worse* 2) EBV mono - pharyngitis & lymphadenopathy (*MC*) EBV Mono -cp: fever, *exudative pharyngitis, splenomegaly* -Cx pe: *posterior cervical lymphadenopathy* -comp/NBS: splenic rupture = *NO contact sports 21d* -Tx: supp; *amox* --> distinct maculopapular *rash* (if Tx-ing for *strep*)
coagulopathic emergencies (5)
1) DIC/consumptive coagulopathy - 2 problems (hmrg vs clot; may counter-intuitively need heparin) 2) HUS/TTP - hemolysis, uremia, low PLT - FAT-RN - may need plasmapheresis if TTP or both (HUS is self limited) 3) ITP - isolated thrombocytopenia; needs CS, IVIg, and rarely splenectomy if refractory or recurrent 4) HIT: try to use LMWH, NOAC; avoid PLT transfusion (can lead to thrombosis)
3 main GYN cancers - think? -cp -rFx -NBS
1) ENDOMETRIAL -post-menopausal woman w/ new onset vag bleed -DM, obesity, *nulliparity, early menses, late menopause* (incr hormone exposure to body) -Dx: EMB-US 2) OVARIAN -elderly F w/ *malignant pleural effusion &/or ascites* -famHx, infertility, low/null-parity, *hi fat diet* -NBS ovarian Bx 3) CERVICAL -young F w/ mult sex partners w/ post-coital bleeding -PMHx of STD's, missed pap smear screens -NBS pap, biopsy
Cx PE signs on CXR (not mc, but Cx)
1) Hampton's hump: wedge shaped area of infarct 2) Westermark's sign: collapse of vv. distal to PE
AC & NOAC - MOA & mgmt/reversal
1) Heparin: activates antithrombin --> inactivates factor Xa & thrombin; protamine sulfate 2) Warfarin: vit K ant --> blocks vit K dep clot factors 2, 7, 9, 10, C&S; FFP or Kcentra 4x PCC 3) tPA: *P*lasminogen *A*ctivator --> plasmin degrades cross linked fibrin clot --> FDPs 4) Factor Xa inh (Api*Xa*ban/Eliquis or Rivaro*Xa*ban/Xarelto); Kcentra 4x PCC to replace Fx10 5) Direct Thrombin (IIa) Inh (Dabigatran/Pradaxa); give Idarucizumab/Praxbind (MAB) warfarin acts on 4 places (2,7,9,10/X) heparin acts on 2 places (X/10, thrombin/2) NOACs both act on 1 place (more specific/clean) tPA acts most distally
what prolongs duration of axn of Sux
1) Liver Dz: decr [cholinesterase] so more Sux 2) NMJ Dz: MG has auto-Ab's against ACh-R 3) famHx of malignant hyperthermia Sux metabolized by plasma cholinesterase
Trimalleolar fracture - what are the 3
1) MEDIAL MALLEOLUS Fx 2) LATERAL MALLEOLUS Fx 3) POSTERIOR MALLEOLUS Fx (aka *POSTERIOR distal tibia* which req lateral view)
3 types of hydrocephalus
1) NPH 2) non-obstructive aka ex vacuo: cerebral atrophy --> passive enlargement of ventricular space 3) obstructive: 2/2 tumor or shunt blockage
2 main types of nephritic syndrome -pp -Dx -comp -Tx
1) RPGN (rapidly progressive) -pp: IC/Ab deposit in glomeruli --> *crescent formation* -Dx: biopsy + *UA w/ RBC casts* -comp: ESRD -Tx: CS 2) PSGN (post strep) -pp: GAS invades glomeruli -Dx: bx; comp: ESRD (rare, mostly self limited) -Tx: *amox*
coin esophageal FB mgmt
1) Sx (regardless of loc) or in trachea? --> remove via bronch vs endoscopy 2) no Sx *AND* in *esoph* --> obs for 24 hrs. if still not passed --> endoscopy or watchful waiting w/ weekly XR 3) if in *stomach* --> can be discharged as most pass in <2 wks. need *weekly plain films*. if *> 4 wks* and still in stomach --> endoscopy
Anticholinergic Toxicity - how to Tx stepwise
1) Tx *AMS & delirium w/ Benzo* 2) Tx *wide QRS w/ sodium bicarb* 3) *Physostigmine (antidote) IFF* if benzo not working or refractory Sz, arrhythmia or hyperthermia
HF Tx
1) apply *topical* Calcium gluconate gel 2) *if pain persists* --> inject Calcium gluconate *intra-dermally* (avoid fingers) 3) *if pain persists* --> inject Calcium gluconate *intra-arterially* *c/i: NOT into fingers* resolution of pain = succesful Tx
GTD types -what is it -types
1) benign: non-cancerous tumor in uterus a) *partial molar preg*: fetus w/ cardiac activity 2/2 *extra set of paternal Chr* in a fertilized egg = 69,XXX or 69,XXY b) *complete molar preg*: no embryo detected at all 2) malignant GTD: invasive mole ie *choriocarcinoma* (b9 neoplasm of placental hCG prod trophoblasts) -Tx: chemo
fx suspicious for child abuse (5):
1) bucket handle/chip fx: epiphyseal avulsion fx @ tibia or femur 2/2 being grabbed/shaken (pic) 2) mid-shaft humerus (not supracondylar) bc req a lot of force 3) mid-shaft tibia 4) vertebral compression 5) Rib fx: lateral and posterior parts of rib Mid (2), VCR
Pt swallows needle - XR neg. NBS
1) call child services 2) get endoscopy so call GI needles can be radiolucent on XR
STATUS EPILEPTICUS STEPS
1) ck blood GLU 2) airway adjunct: chin lift, head tilt, NRBM 3) *BENZO*: ATIVAN 0.1 mg/kg IV *repeat* *L*orazepam is *L*ong acting 4) if you order 2LTx (*phenytoin 20 mg/kg*) then... 5) prep for *intubation*; induce w/ *Propofol* 1.5 mg/kg unless BP issue. paralyze w/ Sux 6) search for reversible causes
2 main tests for brain death protocol
1) cold calorics aka oculo-vestibular reflex: irrigate ear with ice cold water. if brainstem & cortex fxn *in tact, nystagmus to opposite ear.* (COWS = Cold Opposite, Warm Same) 2) Doll's Eyes aka oculo-cephalic reflex: Move head. If brainstem *intact, eyes move in opposite direction* OPPOSITE = GOOD
Pt on vent goes into cardiac arrest - NBS
1) d/c Pt from vent 2) start CPR 3) place b/l chest tubes 4) IVF bolus plateau P likely too hi 2/2 auto PEEP in setting of possible PTx. they will have decr VR so IVF helps and no time to check for b/l PTx so place b/l chest tubes
peroneal/fibular n. a/w which 3 injuries
1) femoral shaft fx (peroneal comes off sciatic n. on posterior side) 2) knee dislocation 3) tibial plateau: deep peroneal
2 fx unique to PEDS @ identical location
1) greenstick: incomplete transverse fx 2) buckle/torus: transverse but 2/2 compression both at metaphysis (contains physis & epiphysis)-diaphysis (shaft) jxn
HCAP indications
1) hospitalized for 2+ days w/in last 90d/3m 2) reside in nursing home/long term care facility 3) i-c 4) receive home IV Abx/chemo/chronic would care/HD w/in last 30d/1m
when should an escharotomy be done
1) if *circumferential* burns of *chest or neck* (can impair breathing as eschar becomes restrictive) (cut along anterior axillary lines) 2) if *circumferential* burns of *limbs* (risk for compartment syndrome) (avoid flexor/extensor surface of fingers, do on side)
6 reversible causes of seizures
1) infxn --> give acyclovir & Abx 2) eclampsia --> give Mg 3) INH tox --> give B6 (pyridoxine) 4) EtOH w/d --> more benzo (Librium too) 5) hypoNa --> give bicarb or *3% NS 2 ml/kg* rpt in 10m 6) CN tox --> give hydroxycobalamin or CN antidote kit (amyl nitrate, sodium nitrite, sodium thiosulfate = *ASS*) *IEIEHC*
DKA pp (2)
1) insulin deficiency --> GLU cannot be brought into liver and muscle and fat cells to use & store --> instead metabolize TAG's & AA --> FA convert to *ketones* ii) excess GLU in blood --> glucosuria --> osmolyte effect --> *e- depletion & dehyd*
NAC indications
1) level above nomogram line 2) suspected toxic dose (ie >150 mg/kg = 10.5 g in 70 kg) 3) *unknown time of ingestion & APAP > 10* 4) hx of APAP OD + evidence of transaminitis
emergency contraception Tx (2)
1) levonorgestrel (plan b): P-only, OTC; 4d after sex 2) Ulipristal (Ella): need Rx; 5d after sex
two types of priapism -pp -ABG -US
1) low flow (veno-occlusive, ischemic) - *mc* -pp: sluggish blood flow in obstructed vv. -ABG: deoxygenated blood -US: decr or no flow 2) high flow (arterial) - *rare* -pp: from direct injury to penis or spinal cord -ABG: oxygenated blood -US: normal flow
shoulder dislocation see on XR - what other co-injuries need to be r/o?
1) mc: Hill-Sachs deformity: humeral head fx 2) glenoid rim fx (Bankart's lesion)
indications for hyperbaric oxygen (HBO) for CO exposure (5)
1) neuro Sx (LOC, coma, Sz) 2) CO *> 25%* or *> 15 % in preg* woman 3) cardio (MI, dysrhythmia) 4) end-organ dmg 5) persistent Sx after HFNC neuro, cardio, 25, Sx, end organ dmg: *25 SCEN*e
what 3 areas can someone lose enough blood to become hypotensive?
1) pelvis so think *pelvic fx* 2) chest 3) abdomen ie HEAD BLEED WONT CAUSE htn
step on sea urchin - you step on. NBS?
1) pull out spikes with tweezers 2) apply *vinegar* vigorously 3) soak in *hottest possible water* 30 mins 4) *vinegar again* 5) ensure no signs of infxn (red, swelling, fever); abx?
top MC carpal bone fx
1) scaphoid 2) triquetrum
same Pt comes back with now bloody diarrhea & fever - NBS
1) send stool Cx 2) extend Abx to 3 days
sciatica causes/DDx (4):
1) spondyolysis: defect in *pars interacularis* --> spinous process fx 2) spondylolisthesis: same as spondyolysis with *ant displacement of vertebra* 3) spinal stenosis: neuropathy *worse w/ bending forward* 4) piriformis syndrome: sciatic n. caught on piriformis worse w/ *prolonged sitting on a hard surface*
GERD Tx algorithm
1) start with *PPI first*: BI Tx bc strongest suppressor of gastric acid secretion (pantoprazole, protonix) 2) after healing has started, H*2* blocker *2*nd for maintenance Tx (Famotidine, Pepcid)
bedside Dx tests for MG
1) tensilon/edrophonium test (AChEi so incr ACh to bind @ blocked ACh-R): look for improvement in ptosis; can cause brady so need atropine near 2) ice pack: over Pt eye, look for ptosis to improve
accidental epi pen injxn - NBS? if still doesn't work?
1) topical nitro/NG 2) place glove over paste (as to not wash paste off) 3) place hand in warm water (v/d to release heat) 4) if *still painful: phentolamine (α-1 ant)* injxn (rmr α-1 = v/c)
mcc (top 3) of tamponade
1) trauma 2) neoplasm 3) ESRD/uremic
SVT Tx algorithm
1) vagal 2) adenosine: 6, 12, 12 (rel c/i in asthma) 3) CCB (Cardizem 20 mg IV) 4) BB (Lopressor 5 mg IV)
what to look for on XR for Lisfranc fx
1) widening of space b/w 1st & 2nd MT 2) intra-articular fx of base of 2nd MT
where should chest tube be placed in preg mom?
1-2 levels higher: 3rd ICS ant/mid ax line
PTx typically resolve @ what rate?
1-2% a day (so if 15% PTx, expect for it to resolve in 2 wks)
fx ribs 1-3 assoc w/ fx ribs 9-12 assoc w/
1-3: mediastinal injury 9-12: intra-abdominal injury
The Infectious Diseases Society of America (IDSA) guidelines on UTI Tx
1. nitrofurantoin (macrobid) for 5d 2. TMP/SMX (bactrim) for 3d
how many kidney stones Pt wont have hematuria mc mis-Dx of AAA 4 types of kidney stones mc type of stone
1/5 = 20% AAA mis-Dx as renal colic kidney stones *SUCC: S*truvite, *U*ric acid, *C*alcium, *C*ysteine mc = Ca
in LP CSF studies, whats normal ratio of RBC:WBC in traumatic tap
1000 RBC: 1 WBC (so if 1K RBC and 6 WBC, abnormal)
laceration repair timeline
12 hr for most; 24 for face/scalp
post LP HA begin when?
12-48 hrs after LP
absolute c/i for tPA
12333-ANY 1 wk hx arterial puncture @ non-compressible site 2 wk hx of any major surg 3 wk hx GI/GU bleeding 3 mo hx of MI 3 mo hx of stroke or head trauma ANY hx of ICH
ICH/SAH BP MGMT
140-160 use nicardipine > labetalol (either oK tho)
hemorrhagic shock classification: amt of blood loss, VS changes
1: < 15% - *no change* 2: 15-30% - tachy 3: 30-40% - htn, *AMS* 4: 40+% think Tennis scoring system: love/0, 15, 30, 40
Pt w/ ICH on warfarin. best options for reversal & why?
1LTx: *Kcenta 4Fx PCC* along w/ *vitamin K*: -acts w/in *minutes* -*BUT short duration* so *need vitK w/ it which has delayed onset but sustained effect* -if *fatal: vit K 10 mg IV* (1 mg/min to avoid anaphylaxis) 2LTx: *FFP* (all clotting Fx w/ fibrinogen) *+ vit K* -2nd *bc delayed onset of axn*; vit K also same so not enough acute fx
Pt w/ CAP (PNA) - 1LTx? if fails NBS? doxy in PEDS?
1LTx: amox (hi dose). if fail, cover for *atypical (mycoplasma)* doxy: *tooth discoloration if used > 14d in < 8 y/o*
SAH main rFx
1º degree relative w/ hx cerebral aneurysm
1º (baby) tooth falls out - NBS 2º (baby) tooth falls out - NBS? steps?
1º: no need to replace. new tooth will grow. 2º: *replant ASAP*: i) rinse *BUT DO NOT SCRUB* (you'll wear off periodontal ligament) ii) put in pH balanced cell-preserving solution (*Hank's*); backup is *milk or saliva* (keep under tongue)
Frostbite classification
1º: superficial (epidermis), *erythema* 2º: full thickness (dermis), *clear blisters* 3º: hypodermis, *hmrg-ic blisters w/ skin necrosis* 4º: *to bone*
amides vs ester
2 'i' = AMiDE (bupivacaine, lidocaine) 1 'i' = ESTER (procaine, cocaine)
in meningitis, how much time you have from Abx given to get Cx?
2 hours - so basically do not delay for CT or LP to start Abx
bupivacaine dose
2 mg/kg w/ *Epi: 3* mg/kg: Epi *decr risk of toxicity* (think if there's more v/c, there's less drug circulating)
osmolar gap - eqn? nl? positive indicates presence of what
2(Na) + GLU/18 + BUN/2.8 + EtOH/4.6 nl *<10* (+) (ie > 10) = presence of an unmeasured low molecular wt solute (EtOH, EG, isopropanol, MG, mannitol, etc)
MAP eqn
2/3 DBP + 1/3 SBP
target UOP for rhabdo or. AKI
200 cc/hr (3 ml/kg/hr)
in a hemothorax, how much blood needed to appear on CXR? -Tx? size?
300 mL -large bore chest tube (ie *36 Fr*)
upper GI bleed BUN:Cr ratio
30:1 (blood is digested in upper GIT to protein and then metabolized to BUN in the urea cycle within the liver. Higher BUN values are therefore associated with the *digestion of blood in upper GI tract*)
neck trauma zones: structures within & NBS
3: salivary glands, pharynx --> CTA head/neck 2: int/ext *carotid aa, IJV*, larynx, *esophagus*, recurrent laryngeal n., *trachea, thyroid* --> angiography 1st if stable, if not emergent surg 1: *subclavian aa./vv., common carotid aa., trachea, esophagus*, thoracic duct --> *CTA, esoph eval, bronch*
3º Syphilis -cp -infectivity
3º -4-7 yrs after chancre, Pt starts to develop tree bark *aortitis, gummas* (sift tumor-like masses of inflm on face), *neuro Sx* -*no* longer infectious
Parkland formula
4 * % BSA * wt in kg -give LR -only for 2º, 3º burns -give 1/2 in first 8 hrs -give rest in last 16 hrs
Hidradenitis suppurativa -loc; pp; mcc -cp -def Tx
4 A's -*A*xilla; chronic infxn of *A*pocrine glands; S. *A*ureus -*A*fro American with abscess in arm pit -Tx: surg is definitive
lidocaine dose
4.5 mg/kg w/ *Epi: 7* mg/kg: Epi *decr risk of toxicity by incr how much you can take* (think if there's more v/c, there's less drug circulating)
% of inferior STEMI that involve RV -NBS
40% -avoid NG & morphine (they are preload dependent)
fever mostly develops after this vaccine
8-14d after MMR given
neonatal brady def'n? NBS? if 6 m/o has HR of 45 - NBS?
< 100; *if < 60 - start CPR* 6 m/o w/ HR 45: do NOTHING. just ensure adequate oxygenation/ventilation
for doxy, how long can you Rx in PEDS without concern for tooth discoloration
<21 days OK
intracranial hemorrhages
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A-a gradient
= [150 - (1.25 * pCO2)] - pO2
Tb (Tuberculosis) - what constitutes (+) PPD
> 15 mm: no risk > 10 mm: (mild-mod i-c) DM, IVDU, *immigrants, health care workers* > 5 mm: (*severe i-c*) HIV, organ transplant, close contact to Tb Pt
HA 2/2 brain tumors classically worse when?
@ morning
fecal-oral transmission of hepatitis
A & E "vowel hits your bowel"
anterior vs posterior urethral injury -loc -mcc -clin pres -comp
A: -distal to membranous urethra -*straddle injury* (blunt trauma b/w thighs = falling onto bike crossbar) -delayed presentation -stricture *P: WORSE* -w/in membranous & prostatic urethra -*major* blunt trauma (MVA, fall) -a/w *pelvic fx* -*impotence, incontinence*
anorexia vs bulimia -c/i in both
A: extreme wt loss; a/w distorted body image B: NL/slight decr in wt.; a/w impulse *B*inging/purging c/i in both = *Buproprion* (anti-depressant but *lowers Sz threshold*)
relative c/i for tPA
AABBC: AVM Hx Aneurysm hx Big stroke (>33% of hemisphere) Bleed Cancer/Neoplasm GLU: < 50 or > 400 SHOT: Sz @ stroke onset (Todd's?) HTN uncontrolled (ie > 185/110 while on Rx) Oral AC Trauma/fracture
Types of precautions
ABCD: airborne, basic/standard, contact, droplet -A: for pathogens trans by spores (e.g., Tb, measles, varicella/chickenpox, disseminated herpes zoster & Covid-19); need isolation room, N95 mask for examiner, -B: gloves, etc -C: use PPE for skin to skin, human to human trans -D: for pathogens trans by resp droplets when Pt is coughing, sneezing, or talking.
what poorly bounds to AC (activated charcoal) multi-dose AC indications WBI indications
AC: CN, Hydrocarbons (HC), EtOH, Caustics, Metals (Fe, Hb), Lithium: *CHEC M*y *L*iver mul*T*i: think *T*'s - pheny*T*oin, barbi*T*ura*T*es, *T*egretol (Carbamazepine), *T*heophylline, *T*CA's WBI: sustained/extended-release products, substances poorly bound to AC, ingestion of drug pkt
anterior cord syndrome vs ACA stroke
ACS: paraplegia + loss of PTt below level of lesion ACA: c/l L/E motor & neuro weakness
ingestions w/ hi AG vs hi osmolar gap
AG (3): methanol, ethylene glycol, ethanol (if + ketoacidosis) OG (4): methanol, ethylene glycol, ethanol & *isopropyl alcohol*
AIN vs ATN -pp -cp -Dx -Tx
AIN: Acute Interstitial Nephritis -immune mediated 2/2 *Rx* (PCN, Sulfa, fluoroquin, diuretics, NSAID) -cp: Pt on *new Rx 3-5d ago* w/ fever, rash, arthralgia; CBC shows *Eos* -Dx: biopsy + *UA w/ WBC casts + eosinophiluria* -Tx: stop medication ATN: Acute Tubular Necrosis -prolonged renal ischemia (*not from htn*) -cp; Dx: biopsy + *UA w/ muddy brown granular & epith cell casts*
pure motor, fatal Dz
ALS: UMN & LMN affected but *sensation in tact*
VF Pt. shock given immediately, still in VF. now 2 mins CPR. NBS?
ANOTHER SHOCK! not Epi yet. best Tx for VF = defib. eventually you give Epi but whats going to help Pt most is shocking so 2 shocks > 1 epi
all cord syndromes
ANT: loss of motor & PTt b/l below level of lesion (*no laterization*) CENT: motor weakness of b/l arms (*no laterization*) BSS: *c/l loss of PTt + i/l loss motor & PVT* 1-2 levels below lesion (rmr ALS decussates across at vertebra)
Tx in both
ANTIHISTAMINES
mc surgical emergency of pregnancy expected leukocytosis in pregnancy
APPENDICITIS - WOW > 18K (rmr expected physiologic change in preg = higher than normal WBC)
mcc of drug induced angioedema hereditary angioedema - how to Dx during acute attack ACE-i indunced angioedema pp? Tx?
ASA HAE: low C4 complement ACE: *excess BK*; Tx: FFP has kinase which can break down BK but also kininogen (precursor to BK) so mixed, regular allergic Tx or *icatibant* (BK-R ant)
tinnitus in overdose - think -earliest Sx in this tox; how does it help -cp -Tx goals -comp of Tx
ASA/salicylate toxicity -earliest Sx = *tinnitus* - as this resolves, you can clinically say the toxicity is improving -cp: N/V, *AMS, hyperthermia, death* -Tx: *IVF resusc* w/ NS *& bicarb* -comp: *drowning the Pt --> ARDS*
oil of Wintergreen in tox - think
ASA/salicylate toxicity! very [hi] so even small amt is dangerous
#1 cause of ARF
ATN
duration of hip dislocation a/w -how to Dx?
AVASCULAR NECROSIS -missed on XR need *MRI*
bell clapper deformity
Abnormal attachment of testis in the scrotum (rFx for torsion) where it's *NOT attached to tunica vaginalis* --> *incr mobility & horizontal lie* w/in scrotum
for post-transplant Pt, common Px Abx when do opp infxn usually come up in Pt mcc death in recipient of transplant? mcc?
Abx bactrim for PCP PNA, Toxo opp infxn AFTER 1st month (bc full effect of immunosuppression hasn't yet all the way kicked in) death: *infxn* > rejection (2/2 immunosuppressants); mc BUG = *CMV* (1-6 mos after surg)
Pt wearing sneakers steps on a nail - NBS?
Abx for *pseudomonas* (found in *sneaker soles*)
Abx worsen this diarrheas Loperamide (anti-diarrheal) specifically worsens this diarrhea diarrhea that presents w/ fever (systemic signs) + bloody diarrhea so NEED Abx/Tx
Abx worsen: E coli (Abx release toxin) Loperamide worsens *Shigella* need Abx: -shigella (needs Abx - IV rocephin or PO azithro) -Entamoeba histolytica (metro + amebicide paromomycin)
High Altitude Illness -types (3) -best way to prevent all -mc form: cp; comp -how to accelerate acclimatization
Acute Mountain Sickness HACE: High Altitude Cerebral Edema HAPE: High Altitude Pulmonary Edema prevent: gradual ascent mc: AMS; cp: HA; if no descent comp = HACE accelerate: after day trip, *return to lower altitude for sleep*
diver has LOC while rapidly ascending - think -pp -comp if these exist -NBS
Air Embolism -bubbles cross alv-cap --> circulation (aa. or vv.) --> Sx mimic PE, MI or stroke -comp (entrance into systemic circulation) if Pt has *PFO/septal defects (ex: VSD)* -NBS: place *LLD & Trendelenburg* (aka Durant's maneuver: air rises to R heart & *traps air in apex of RV* --> *prevents passage thru pulmonary outflow tract*)
low SN but hi SP for biliary etiology in acute pancreatitis
Alt
Hemolytic Uremic Syndrome - triad
Anemia, Renal failure, Thrombocytopenia HASan is an ARTist (*HAS*an does *ART*) rmr add fever + neuro signs = *FAT RN = TTP*
resection of terminal ileum - at risk for these deficiencies
B12, IFx, fat sol vit ADEK
Blunt vs penetrating trauma in diaphragmatic injuries
B: large tears --> herniated GI contents P: small perforation --> takes *yrs* to herniate
how to differentiate bacterial vs fungal/TB meningitis
BACTERIAL have PMN's and gram stain (+) FUNGAL/Tb have LYMPHOCYTES and gram stain (-) -both are HI PROTEIN w/ LO GLU
BB OD vs CCB OD - main distinguishing Fx
BB: less letters so *hypoglycemia*; 1LTx: *glucagon* -BB interrupt gluconeogenesis/glycogenolysis CCB: more letters so *hyperglycemia*; 1LTx: *calcium* -CCB block insulin release from pancreatic islet cells
what structure in brain does CN target T/F: sodium & amyl nitrite c/i if concomitant CO poison
BG TRUE: stick to hydroycobalamin + sodium thiosulfate
radiolucent (U CANT) FB on XR - BI vs MA Dx test
BI: CT. (no oral contrast XR) MA: bronch
which part of body generates most heat during electrocution
BONE: has the highest resistance and the higher the resistance, the more heat that gets generated --> destruction of bone matrix --> osteonecrosis
MCC of urinary retention normal post void residual in adults NBS
BPH post void: < 50 cc NBS: place foley catheter
how to differentiate bacterial from viral
BS: Bacterial uses GLU/Sugar as fuel (so will be Low) VP: Viruses uses PROTEIN as fuel (so will be low)
mcc of sudden death in young men (that are not athletes) -cp -pp -gen -EKG Cx -Tx
Brugada syndrome -sudden death, *syncope* -pp: *sodium channelopathy* —> syncope --> VF -gen: AD -EKG (in T1): Massive *"coved/shark fin" STE in V1-V3* + *TWI* + *RBBB* -Tx: place *ICD*
most C spine fx in elderly and PEDS in this region
C1-3
FOUR
CARDIO
Rash on palms and soles
CARS Coxsackie A Rocky Mountain spotted fever Secondary syphilis,
sacral fx a/w this syndrome
CES: Cauda Equina Syndrome
Child with rectal prolapse - suspect?
CF
cephalohematoma vs caput succedaneum
CH: swelling does *NOT* cross suture lines CS: swelling *does* cross suture lines (sagittal) -mostly Edema, that Extends across -CPS - Can Pass Sagittal -longer word so travels farther both seen in forceps/vacuum delivery & resolve spont
systemic toxicity ingestions
CHAMP: -Camphor -Halogenated -Aromatics (HC) -Metals -Pesticides
ACHILLES TENDON RUPTURE a/w this Rx
CIPROFLOXACIN
currant jelly think these 2
CJ stool = intussusception CJ sputum = Klebsiella
CK vs Mb t-1/2 comp of rhabdo Tx
CK long t-1/2 but Mb t-1/2 2-3 hrs only (returns to NL in 6-8 hrs) rhabdo Tx: over-resusc w/ IVF --> *compartment*
BP eqn
CO = HR * SV MAP = CO * SVR MAP = HR * SV * SVR ^rmr SV mediated by preload, afterload & Cx
CO vs CN poisoning
CO: cherry red lips but normal skin; nl LA; Tx HBO/O2 CN: can have cyanotic skin if severe; LA/HAGMA; Tx antidote
mc ingested FB in PEDS? how to tell where it is?
COINS -*coronal* (pictured): *esophagus* (corona = sun) -*sagittal*: *trachea* (think sagittal suture) rmr esophagus is much bigger and pliable so coin can turn coronal unlike trachea where it goes in like a slot machine
most SN test for detecting placental abruption post trauma?
CONT FETAL MONITORING
main diff b/w chickenpox & smallpox chickenpox adult & PEDS Tx diff
CP: lesions in *DIFFERENT STAGES OF HEALING* (some macules, some papules, some vesicular, some crusted) SP: lesions *ALL IN SAME STAGE* Tx: for adults 10% get PNA so give IV acyclovir. if PEDS, just supportive
ICP equation
CPP = MAP - ICP goal to keep CPP 50-70 helps to decr ICP
CRAO vs CRVO - central retinal a./v. occlusion -cp -fundo exam (3) *IMP* -Tx
CRAO -cp: painless loss of vision, *more sudden* in onset -fundo (3): *pale retina* (d/t retinal edema), *boxcarring* (interrupted columns of blood w/in retinal vessels.), *a cherry red spot* (site of occlusion) -Tx: decr IOP; HBO; *emergent ophtho consult; gentle globe massage* to dislodge embolus, adm 4 *CVA* r/o CRVO -cp: same as CRAO but *more gradual* in onset -fundo (3): *"blood & thunder appearance", cotton wool spots, retinal hmrg* -Tx: no acute Tx (no ASA/AC) but need urgent consult
pneumomediastinum expected - NBS?
CT scan + esophagram
NBS when considering GTD
CXR to r/o METS to lung from choriocarcinoma
chalazion vs hordeolum (stye): pp, cp, Tx
Chalazion (think C is first letter so on TOP) -pp: *C*hronic inflm 2/2 meibomian gland obstruction -cp: *C*hill ie *NON*-tender -Tx: no Abx! (chronic) Stye aka hordeolum (seen on bottom eyelid a lot) -pp: *acute* inflm of eyelid - can be internal (Meibomian gland) or external (glands of Zeis & Moll) -cp: very *TENDER* -Tx: topical *Abx*
cholinergic vs anti meds
Chol - think SLUDGE-MM: need *atropine* (antimuscarinic) + 2-PAM (reactivates AChE to decr ACh) anti-chol - think opposite of SLUDGE: need *-stigmine* (physo/neostigmine = both *AChEi* so incr ACh); also Donepezil & Edrophonium
mcc of 1st trimester spontaneous miscarriage
Chr abnormalities
IBD: Chron's vs UC -loc -comp
Chr: all over but no rectum (skip lesions); perianal *fissures & fistulas, calcium oxalate crystal* UC: colon/rectum; incr (P) of *colon CA & toxic megacolon*
50 y/o M accidentally took whole bottle on warfarin 1 hr ago. No Sx. NBS?
Ck basline iNR & give vit K PO. can d/c and repeat level ck in 48 hrs.
technically not unstable cervical fx but one you should know about -what is it
Clayshoveler's Fracture -stable fx of *spinous process of lower cervical vertebra*
cluster HA prophylaxis what doesnt help a cluster HA
Cluster needs *C*CB: verapamil NC regular - need NRBM!!
MC Fx in > 50 y/o -problem? -assoc w/ what other fx? -complication?
Colles fx -*distal radius fx* w/ dorsal displacement -assoc w/ *ulnar styloid* fx -assess for *median n. injury*
MCC hemoptysis in PEDS -cp -top 3 causes -comp
Cystic Fibrosis -Pt w/ recurrent bacterial PNA -MC: S. aureus, H. influenzae, Pseudomonas (most dangerous) -a/w spont PTx
young child from Central America with multiple ring-enhancing lesions - think
Cysticercosis
INTESTINAL DISASTERS IN INFANTS
DAVIN -Duodenal atresia -Aganglionic megacolon (Hirschprung's) -Volvulus (with malrotation) -Intussusception -NEC less concerning but need mgmt: PMH2 Pyloric stenosis, Meckel's, HUS, Hernia (incarcerated)
intermittent dysphagia - think
DES: Diffuse esophageal spasm 2/2 GERD, stress, hot or cold food, carbonated drinks, smells
how to differentiate red eyes
DIFFERENTIATE EPI vs SCLERITIS Use 2.5% phenylephrine (v/c) drops: -v/c/blanching of episcleral but not scleral vessels --> decr injxn & redness in episcleritis but *NOT* scleritis -red area is mobile if moved with a moist q-tip in Epi but *fixed in scleritis* also episcleritis vs conjunctivitis: Episcleritis has local pattern of injection, as opposed to diffuse in conjunctivitis.
mc early finding in adult with botulism
DIPLOPIA
Acanthosis nigricans a/w
DM (insulin resistance) & gastric carcinoma
<40 y/o with painless hematochezia - NBS
DRE + *sigmoidoscopy*
gastric vs duodenal ulcers -mc? cp? bleed? NBS?
DUD: mc, 2x more likely to bleed (more vascular?) -cp: *better w/ food*, diet unchanged so *no* wt. loss -NBS: no bx nec as no "duodenal cancer" Gastric: -cp: *worse *w/ eating* so there is also *wt loss* -NBS: *biopsy* during endo to r/o malignancy
Abdominal distention + bilious emesis w/in first 24 hours - think -pp -a/w -Dx -Tx/prog
DUODENAL ATRESIA -pp: congenital obstruction of duodenum -a/w *Down Syndrome*, preg w/ *polyhydramnios* -XR: *Double Bubble* sign, S = dilated stomach, D = duodenum that is prox dilated -Tx: surg (*that can be delayed 1-2d*); prog GOOD (*much better than volvulus w/ malrot*)
which stomach ulcer mc? more likely to bleed?
DUODENAL for both
swelling near medial canthus under eye - think? pp? Tx
Dacrocystitis: inflm of naso-lacrimal sac 2/2 obstruction; Tx: warm compress, *PO* Abx (*NOT topical*)
diver ascends too quickly w/ new-onset joint pain - think -aka -primary determinants of risk -mc jt affected -other Sx -Tx
Decompression Sickness -aka Caisson's Dz aka "*the bends*" -duration underwater & depth of dive -joints: shoulder & elbow -Sx: pruritus, erythema, cutis marmorata (venous stasis); *NO LOC* unlike the other 2 -Tx: 100% O2, HBO, IVF
Pt w/ sore throat, fever. you see *spots of gray & white exudates coalescing to form a pseudomembrane* - think? -cause -Tx -how to correlate severity
Diphtheria -mcc: Corynebacterium diphtheriae -if resp only: *Abx (PCN)*; if *systemic = anti-toxin* (if cardiac, neuro or renal involvement) -clinical severity depends on *severity of membrane formation*
SN 100% (ie HI SN) means what exactly
Dz is r/o (NEG) if Test is NEG if SN of D-dimer is 100%, then a neg D-dimer r/o PE
GCS:
E: *P*G/*S*G V: *NIC* VAN M: *EXEL* Eyes: to Pain, to Speech Verbal: Noises/Not comprehensible, Inappropriate, Confused Motor: Ext to pain, fleX to pain, Evades/withdraws, Localizes
early stages of inhalation injury, MCC PNA
EARLY: S. aureus (later is pseudomonas)
posterior cervical LN think
EBV mono
PEDS
EIGHTH
complete heart block
EKG
PULM
ELEVEN
~ cp to PTA (teen/young healthy adult w/ fever, sore throat, trismus and phonation changes *BUT NO DEVIATED UVULA* - think -mcc -cp -Dx: BI vs MA -Tx/NBS (3)
EPIGLOTTITIS -mcc: *H Flu B* adults > kids (2/2 vax non-compliance) -cp: not often stridor & drooling - think *~ PTA w/o uvular deviation* -Dx: BI lat neck XR (*thumbprint sign*); MA: direct visualization w/ bronch -Tx/NBS: i) *first, secure airway*: consult anesthesia & ENT; ii) *2nd = Abx = rocephin*;
ER mgmt of frostbite? how to rmr? T/F: If stuck in env, dont rewarm only to allow to refreeze. Wait until you're in a place where you can rewarm & maintain warmth
ER: rapidly rewarm w/ circulating water at Tº *37-39º (98.6-102.2)* -*Frost-bite, THIRTY-(e)IGHT* T: refreezing causes MORE dmg
order this for transient synovitis vs septic arthritis
ESR & US
MCC of traveler's diarrhea - Tx?
ETEC --> single dose of cipro
eczema vaccinatnum 2/2 to eczema herpeticum -def'n -cp -NBS ^why?
EV 2/2 *smallpox vax*: eczema rxn 2/2 that vaccine EH -eczema that gets 2º infected by herpes virus -cp: infxn in areas of prior eczema Tx'd by CS -NBS: emergent *consult to derm* ^bc *mortality rate = 10%*
external vs internal rewarming
EXTERNAL -passive: removing wet clothes, heated blanket -active: Bair Hugger INTERNAL (4): *warm humidified O2, warm IVF, gastric/peritoneal lavage w/ warm NS, extracorporeal bypass rewarming
meningitis w/ focal deficits - think? -pp -mcc -Dx -Tx
Encephalitis -infxn of brain parenchyma of temporal & inferior frontal lobe --> Gray matter affected --> cognitive / psychiatric signs, lethargy, seizure -herpes encephalitis -MRI + LP -start *IV acyclovir* while results pending
fever w/ back pain DDx?
Epidural abscess Potts Dz Vertebral osteomyelitis Pyelo Zoster
Episcleritis/Scleritis: cp, mcc, Tx
Episcleritis: sudden onset *mild* pain -involves superficial episcleral vessels -Tx: topical NSAID Scleritis: *EMERGENT*; cp: AI Dz --> *SEVERE* pain w/ *decr vision & purple discoloration of globe* -Tx: oral CS, NSAID, *ophtho consult*
Roseola confused with -aka -cp -caused -comp
Erythema infectiosum -aka fifth dz aka "slapped cheek rash" -cp: initial *mild URI --> Abrupt onset facial rash* on day 3-4 (Spares eyelids, chin) for 4-5 days --> Macular erythema on trunk/limbs 2d after facial rash for 1 wk -caused by parvovirus B19 -comp: a/w aplastic crisis, hydrops fetalis THE *FEVER DOESN'T STOP HERE ABRUPTLY*, URI continues; *RASH STARTS ON FACE* HERE, NOT BODY
90% of F who have ectopic preg have at least 1 rFx what's #1? T/F: almost 50% of women can have incr hCG and still have en ectopic T/F: ectopic preg will not heal w/o either surg or med mgmt
F: *50%* have *NO rFx!* #1 is previous hx of ectopic T: hcg going up doesn't rule out ectopic F: some ectopics simply improve with watchful waiting
T/F: in kids w/ epididymitis Tx with UTI
F: Abx unnec. check for assoc UTI
T/F: if child is in a bat in the room and cries and parents come and n obvious bite - can discharge? NBS?
F: CDC says bite can be so small you can miss it NBS: administer *rabies vaccine AND Ig* to Pt and whoever was in room at the time
T/F: low grade fever r/o SAH
F: SAH can have low grade fever
T/F: you can do a NT intubation if Pt is apneic
F: cannot do nasotracheal (consider cric)
T/F: use of CPAP in CHF a/w decr in mortality mcc death in CHF
F: decr intubation rates but not M&M. the thing it does decr is V/Q mismatch. death in CHF 2/2 dysrhythmia
T/F: lightning struck Pt has dilated pupils - stop coding them mc injury a/w lightning strike child chews on electrical cords - think
F: it's 2/2 dysautonomia keep resusc mc: ruptured TM delayed labial artery bleed - in 5 days as bleed starts once scar falls off
T/F: childrens ribs easier to fx
F: kids ribs more pliable so greater force req'd to fx so if there's a fx, be concerned for a high force mechanism and look for other injuries
T/F: consuming liquid mercury from a thermometer is fatal
F: liquid is OK - but *inhaling vapors --> interstitial fibrosis of lungs*
T/F: look for transaminitis in FHC (fitz hugh curtis)
F: liver enzymes NL
T/F: fetus are spared in a preg F electrical injury arrhythmia most a/w lightning strikes AC vs DC - which is worse in prod more severe injuries?
F: mortality is actually hi even w/ low current as amniotic fluid has a low resistance lightning: asystole *AC worse* bc the current ping-pongs inside of you, repetitively stimulating mm. cx ("alternates" from entrance to exit site). unlike DC where the exit of current is worse than the entrance causing a single spasm that throws the Pt --> trauma (ex: lightning is DC)
T/F: serologic testing for lyme during early localized stage can help Dx? given that, NBS? in lyme, likelihood of transmission incr if what?
F: no pt in testing bc takes weeks for Ab's to develop so will be neg so *Tx anyway* -you *SHOULD* test if suspected systemic sx (ie *evidence of early disseminated* dz) if tick is ergorged and/or attached for at least *72 hrs*
T/F: all of child, spousal and elderly abuse are mandatory reportable offenses ^ how is dispo determined for elderly
F: not spousal!! domestic abuse is OK reg dispo in elderly abuse: they have capacity so if they want to discharge with family back home - they can! you are not forced to admit!mcc ac
local anesthetic allergy real?
F: usu allergic to preservative METHYLPARABEN
T/F: normal LA can help rule out mesenteric ischemia
F: will be elevated if there's already bowel infarction but this is a LATE finding early CT findings non-specific (SI thickening, bowel dilation)
T/F: >1 PMN in CSF is normal
FALSE: 1 is OK, >1 is ABNORMAL
T/F: endoscopy or colonoscopy in IE Pt req Px
FALSE: DO NOT NEED PROPHYLAXIS
T/F: Urinary Alkalinization can be a substitute for dialysis in ASA or barbiturates toxicity why is intubating dangerous in acidotic states (DKA, ASA tox, etc)
FALSE: need BOTH for ASA, alkalemia keeps ASA ions in blood and prevents them from crossing BBB. during apnea if resp acidosis --> acidemia, then they can start to cross --> fatal. also matching the Pt's tachypnea on vent is tough. *if you have to tube 2/2 hypoventilation, ensure hi MV (ie TV * RR) & pH > 7.5)*
for caustic agents: T/F: inducing vomiting is recommended T/F: neutralizing agents should not be given
FALSE: vomiting re-exposes caustic agent to esoph TRUE: neutralizing agents release heat --> additional thermal injury
pulmonary contusion NBS on test?
FLUID RESTRICTION (> prophylactic intubation)
mom in cardiac arrest for how long before attempting resuscitative hysterostomy?
FOUR mins
when to intubate for GBS
FVC < 15 ml/kg (normal is 4L so 70 kg < 1050 L is bad) PaO2 < 70 NIF > -20 = bad (-70 is more neg insp force so better)
slapped cheek syndrome think assoc complication?
Fifth Disease (erythema infectiosum) --> *Parvovirus B19* -rmr parvo a/w *aplastic crisis in sickle cell Pt* rash: slapped cheek rash --> reticular (lace-like) on trunk & extremities
generic Abx for G+, G-, anaerobes
G+: PCN or cephalosporin G-: aminoglycoside (gent) or fluoroquinolone (cipro) A: metro or clinda
dry wet gangrene - def'n & Tx
GANGRENE (generally): insufficient blood flow to tissue DRY: necrotic tissue *w/o* 2º bacterial infxn ^Tx: bulky dressings, *prevent it from becoming WET* WET: necrotic tissue *W/* 2º bacterial infxn ^Tx: IV Abx, *emergent surg for debridement*
suspected achilles rupture but negative thompson test - think -clin pres
GASTROCNEMIUS RUPTURE -tennis player suddenly changing direction
cholecystitis key US finding choledocholithiasis key US finding
GB wall thickened *> 3 mm* CBD dilatation *> 6 mm* (+ 1mm per decade after 60 y/o)
strep with neg gram stain in meningitis
GBS
mcc of neonatal PNA -rFx
GBS -rFx: preterm, prolonged ROM
date rape drug w/ cp of intermittent agitation then return to comatose state - think -comp -Tx
GHB: Gamma-Hydroxybutryic acid -comp: hypothermia, brady without overall hemodynamic compromise -Tx: supp
FIFTH
GI
colchine A/E? c/i? imp note to rmr? Pt on AC, NBS?
GI A/E, peripheral neuropathies (reversible) c/i in severe renal or heaptic Dz imp: NEVER GIVE IV --> death AC so no NSAID --> *low dose colchicine w/ CS* (better if mult jt's involved for CS to work)
upper GI bleed mgmt in cirrhosis/portal HTN
GI BLEED *PIVOT* = mgmt Protonix/PPI bolus 80 mg Infxn (Abx rocephin or cipro) Vasopressin Octreotide Txa
HHS (hyperglycemic, hyperosmotic state) labs
GLU > 600 osm > 320 bicarb > 15 or pH > 7.3 (ie not acidotic) can be neg or low ketones
monteggia fx - which n. involved?
GRI-*MUS*: Monteggia fx = Ulna bone so think *RADIAL N.*
hantavirus vs tularemia: animals involved & spread
H: think rodents - NOT contagious T: think rabbits - VERY contagious
Herpangina vs herpes gingivostomatitis: mcc, cp, how to diff, Tx
HA: -2/2 Coxsackie A (HFM Dz minus the hands and feet) -very *contagious* oral vesicles that rupture & develop into painful pulcers -ulcers *isolated to soft palate, uvula, tonsil* -last 7-10d, heal spont HGS (pic): -2/2 HSV -ulcers on soft palate, uvula, tonsil *PLUS gingiva, buccal, tongue*; lesions may precede classic lip ulcers -a/w *gingival hypertrophy* -Tx: acyclovir
mcc death among all the HAI -cp -can present as -Tx -Px
HAPE: High Altitude Pulmonary Edema -cp: initially only non-prod cough + SOB, but prog to *ARDS* om 2-4 days *after rapid ascent* -can present as PNA in RML -Tx: *O2* > descent; *Sildenafil* (Viagra, PDE-5 inh) can help w/ dilation of pulm vasculature -Px: *CCB* (Nifedipine) - same as viagra
earliest EKG change of STEMI
HATW: *hyperacute T wave* HATW --> STEMI --> Q wave --> TWI
what to check for Hep B immunity?
HBsAb (you have the Ab against hep B)
hallmark for Dx for hep B
HBsAg
this Rx helps prevent mc stones from forming problem with uric acid stones? Tx? rarest form of stone? a/w? most common site of stone impaction? besides incr IVF consumption, what else can you tell kidney stone Pt?
HCTZ: Higher Calcium (in serum, *but decr urinary Ca excretion* so helps prevent stone formation) radiol*U*cent so U CANT see them; allopurinol helps reduce formation (same as gout) cysteine stone; a/w inborn errors of metabolism narrowest part of ureter = UVJ diet: *incr lemonade/OJ intake*. citrate binds Ca in urine --> CA not binding oxalate/phosphate = less stones
if meningitis is your Dx, when should you get CT before LP (4)
HI RISK (4): i-c, >60, focal deficit, hx of AMS/CNS Dz
T/F: PEP in suspected HIV should be delayed for testing bc A/E are numerous HepB possible exposure - NBS
HIV- F: do not delay, the earlier you start the better NBS: *check HBsAg* (rmr, *hallmark for Dx*) if *NO* hx of vax. if hx of vaccine, *check titers*. -if *titers low/incomplete vax* series: should get PEP *if HBsAg (+); PEP = Hep B Ig + Hep B vax* BASICALLY wait for HepB lab work to start PEP but *DO NOT WAIT in HIV*
VS changes in 1st trimester A/B status change in preg
HR up by 15 SBP/DBP both drop by 10 (until 28 wks) normal to be in resp-alk 2/2 hyperventilation w/ comp met-acid (diaphragm compressed by uterus)
mc exam finding in dsxn
HTN
which HTN emergency finding most easily reversible w/ Tx
HTN encephalopathy
match bug to bite: cat, dog, human, reptile
HUMAN BITE: *Eikenella* (Ike n Ella are humans) CAT/DOG BITE: *Pasteureulla* (Pasteur is animal) REPTILE BITE: *Salmonella* (salmon have reptile type skin)
mc e- disturbance in malignancy -sx; ekg; Tx
HYPERCALCEMIA -sx: bones stones moans groans; short QT; NS & CS
diminished DTR first sign in this e- abnormaltiy
HYPERmagnesemia: think PTL Pt w/ epilepsy getting Mg Hi Mg, hypo/lo DTR
HZO vs HSV keratitis
HZO: is keratitis + rash (involves *ophthalmic branch* of trigeminal n./CN V) HSV: involves *just cornea* has dendritic pattern Tx for both: oral anti-virals, topical CS, IV antivirals
HINTS exam - concerning findings (ie central findings)
Head-Impulse—Nystagmus—Test-of-Skew *HI*: on side you're worried for CVA, if *NO* corrective saccade = BAD = STROKE. having a saccade is (+) but for a peripheral n. lesion (vestibular n.) *CONFUSING bc (-) HERE = BAD BC (+) = PERIPHERAL* *N*: benign nystagmus = U/L & Horizontal - rest is concerning for *CVA, esp VERTICAL/BI-DIRECTIONAL* *ToS*: *skew deviation = ab-NL vertical correction* ~ saccade but this is *VERTICAL* = eye jumps up to re-focus = (+) CVA; nl = no movement *CVA = HI ((-) saccade) + N (vert/bi) + ToS ((+) skew dev)* -rmr *vertical = BAD* (for Nyst & ToS)
hemophilia A vs B how to deal with head trauma cases doses
Hem A (Fx 8 def) (think *A*te (8)); Hem B (Fx 9 def) trauma: give factor *BEFORE GOING TO CT* & continue Tx *whether or not imaging evidence of ICH bc risk of delayed bleeding is HI* (mcc death in trauma = ICH) doses: *Fx8 = 50 U/kg; Fx9 = 100 U/kg* Fx8 req'd = kg x 0.5 x (% activity desired) Fx9 req'd = kg x 1.0 x (% activity desired) assume 100% for severe bleeds and 50% for moderate
neonate w/ delayed passage of meconium & absence of stool in rectal vault -aka -pp -cp -Dx -comp
Hirschsprung's Dz -congenital aganglionic megacolon -pp: absence of ganglion cells in distal colon (rectosigmoid) -cp: *neonate w/ delayed passage of meconium & absence of stool in rectal vault*, distention, emesis (in elder kids, they can just have chronic constipation) -Dx: rectal *biopsy or manometry* -comp: a/w *toxic megacolon*
MoA & pro/con of IV anti-hypertensives: HLD
Hydralazine: direct aa. vasodilator; good in preg induced HTN; bad in ACS bc incr myocardial O2 demand Labetalol: alpha & BB; good in dsxn or CVA; c/i in asthma, CHF & brady (need beta agonist not BB) Nitrates: dilate *both* aa. & vv. --> significant drop in BP even in small doses; good in CHF; causes reflex tachy
when to suspect diabetes insipidus? types (2) w/ mcc? how to differentiate?
HyperNa/Hyper Osm with dilute urine (decr urine osm) i) central/neurogenic DI: decr secretion of ADH (idiopathic, head trauma, neoplasm) ii) nephrogenic DI: ADH secretion OK but decr renal SN to ADH: Li tox, nephrotoxic Rx, hypoK, hyperCa diff by giving ADH: central will respond, nephro will not
ingestions you can dialyze
I STUMBLED: Iron/INH, Salicylates, Theophylline, Uremia, Methanol, Barbiturates, Lithium, Ethanol/Etylene glycol, Depakote
infective endocarditis mnemonic
I got IE: FROM JANE (fever, roth spots (retinal hmrg), osler nodes (fingertips), murmur, janeway lesions (palms/soles), anemia, nail hmrg, emboli (septic valvular vegetation))
LeFort Fractures: classification -~ to? -worst ones? -all fx do this
I: *hard palate* (upper alveolar ridge is free floating) II: *orbital floor* III: moves posterior to *zygomatic --> CRANIO-FACIAL DISRUPTION* -~ to *neck zones*, 1 to 3, you *move UP the face* -worst: *II & III* - think airway compromise, C-spine injuries, CSF rhinorrhea, malocclusion of teeth -ALL LeFort: extend to post face --> *fx of pterygoid plate*
Pyoderma gangrenosum - a/w? -misnomer? -cp
IBD (Chron's) -misnomer bc not infectious nor gangrenous. "pyoderma = pus on skin" -inflm pustule --> painful ulcer w/ violaceous border on purulent base
painless honey crusted lesions on child's face - think -what is it -mcc -Tx
IMPETIGO -contaigous superficial bacterial infxn -mcc: *S. aureus & GAS* (Strep pyogenes) -Tx: *mupirocin* (ointment) or *dicloxacillin*
Physiologic changes in pregnancy
INCR (4): *HR, CO, WBC, TV* (no change in RR but may have subjective dyspnea) DECR (3): *BP* (in *2nd tri*mester), *BUN/Cr, delayed GI motility/gastric emptying*
pathognomonic for MS
INO: b/l *Inter-Nuclear Ophthalmoplegia* "I NO" see "NO"se: when looking L, R eye won't adduct. when looking R, L eye won't adduct.
1 y/o w/ viral illness last week with now intermittent crampy ab pain draws legs up w/ pain free period b/w episodes w/ syncope 2d - think -age range -Cx pe -pp
INTUSSUSCEPTION -3m/o - 3y/o -may feel sausage shaped mass on R side -think of *lead pt*: in viral illness, hypertrophied lymph tissue in GI. in older PEDS, polyp or hemangioma. in CF, thick stool 2/2 lack of pancreatic enzymes
mcc of intestinal obstruction in 3 mos - 6 y.o? mc Tx?
INTUSSUSCEPTION -Tx: Stable Pt (ie no evidence of perf) Tx non-op rdxn: -NPO, NGT -*Air-contrast enema (reduces 80%)* -Hydrostatic (NS or water-soluble contrast) 2LTx
isolated thrombocytopenia - think -S/S -Tx? indications (2)?
ITP: Idiopathic Thrombocytopenic Purpura -S/S: petechiae, purpura, bruise, epistaxis in F -1LTx: CS (*prednisone*) - not all need it i) if PLT < 30K ii) if PLT < 50K w/ active bleed other Tx = IVIg or *splenectomy* (if refractory or recurrent)
GBS Tx
IVIg (*NOT steroids*)
jones vs pseudojones: what is it + mgmt -how to differ
J: transverse fx at *base of 5th MT* + consult ortho for poss surg, splint & non weight bearing PJ: *avulsion fx* of tuberosity of 5th MT + hard soled shoe & wt bear prn measure from prox tip of 5th MT to fx site. if: >15 mm = MT shaft stress fx *<15 mm* = Jones *OR* Pseudo-Jones
JCo accrediation lasts how long paramedic hierarchy T/F: EMS med director does NOT have to be board certified in EM online vs offline med control T/F: parents refuse life saving Tx for child - EMS does not have to contact med control 3 EMS models
JCo - 3 yrsz paramedic: EMT-Paramedic > EMT-Intermediate > EMT-Basic TRUE: does nOT! online: EMS talk directly to physian offline: EMS refers to standing orders T: EMS does not and they can just Tx themselves i) public private: public fire dept is 1st response and later met by a private EMS ii) third service: municipal dept in charge of everything iii) station based: fire dept responds to ALL CALLS
Unstable C-Spine Fractures
Jefferson Bit Off A Hangman's Tit/Thumb Jefferson Fx Bilateral facet dislocation Odontoid T2&3 Atlanto-Occipital dissociation Hangman's Teardrop
jones vs pseudojones fracture on XR - why does distinguishing matter
Jones fx has incr risk for MALUNION
criteria for flexor tenosynovitis
KANAVEL SIGNS 1) *F*usiform swelling (ie sausage digits) 2) pain w/ E*X*t (earliest sign) 3) *T*TP along flexor tendon 4) finger *S*tuck in flexion *FX TS* = *F*usiform, e*X*t = pain, *T*TP, *S*tuck in flexion
fetomaternal hemmorhage detected using this
KB test (Kleihauer-Betke): solution added to maternal blood - adult cells colorless but fetal RBC;s turn bright purple/pink
septic arthritis criteria
KOCHER CRITERIA: can be exclude if following are (-) -ESR > 40 -CBC WBC > 12 -fever -non-weight bearing
HIV M who engages in MSM with new purple/red lesions in mouth & legs - think -what is it -NBS
Kaposi Sarcoma -neoplasm 2/2 abnormal angiogenesis mostly on *L/E & in mouth* = flesh colored, dome shaped papule -NBS: biopsy
leading cause of acquired heart disease in children -how to Dx
Kawasaki Dz -*CRASH: fever > 5d* + 4/5 of the following *C*onjunctivitis *R*ash (starts on palms/soles) *Adenopathy (cervical)* *S*trawberry tongye *H*ot *H*ands/feet w/ desquamation/peel, erythema, edema The Kawasaki car CRASH'd or can be a SCARE: Strawberry tongue, Conjunctivitis, Adenopathy, Rash, Erythema on Extremities
ASTHMA best induction agent for asthma why PEEP avoided in asthma? this measure directly correlates w/ chance of barotrauma ^how to modify? why COPD less amenable to Tx like Mg (sm mm relaxant)
Ketamine PEEP good in CHF but bad in asthma. (+) P at end of expiration when air has trouble escaping in an obstructive disease will lead to air trapping --> auto PEEP --> incr intra-thoracic P --> decr VR/CO/BP barotrauma: Plateau P; can go up if incr auto PEEP ^lower plateau P by decr TV/PEEP Mg: bc COPD is not fully reversible unlike asthma
indications for liver transplant following APAP OD
King's Criteria: acidotic pH (ie < 7.3) not responsive to IVF INR > 6.5 Cr > 3.4 hepatic encephalopathy (grade III or IV) rmr liver enzymes convey evidence of liver dmg but don't say anything about FXN!
L MCA vs R MCA cp
L MCA: a/w *aphasia (*L*eft for *L*anguage) -rmr L hemisphere considered dominant as it controls R side motor and most ppl R handed. R MCA: a/w *hemineglect* (*R* for o*R*ientation)
hip fx ie femur fx clin pres -how does this differ
L/E: *shortened & ext rot* -if hip dislocation: leg is still shortened but *INT* rotated
PSYCH
LAST 18
COMPARTMENT SYNDROME L/E compartments
LATERAL ANTERIOR (mc) DEEP POSTERIOR SUPERFICIAL POSTERIOR (no medial bc thats essentially where tibia is)
repetitive use: MG vs LEMS
LEMS: improves with repetitive use MG: *worse w/ repetitive use*
LGL: Lown-Ganong-Levine EKG ~ to?
LGL ~ to WPW (both short PR) but diff is *no delta wave*
mc injured organ in ALL of abdominal trauma
LIVER li*ver* o*ver*all (including penetrating)
c/i in epiglottitis
LMA (supraglottic airway): pushes swollen epiglottis down over laryngeal inlet/cords
which properties of hydrocarbons increase toxicity potential (3)
LOW viscosity & LOW surface tension + HI VOLATILITY
GI Sx + PNA - think? -Cx rFx -Cx Sx -Cx labs -Dx? -transmission?
Legionella PNA -rFx: water sources & A/C units -Sx: AMS, *brady, N/V/D* -labs: *hypoNa, transaminitis* -Dx: *urine Ag* -trans: no person to person
LVAD patient unresponsive - NBS
Look: all lines connected? Listen: motor working? if not, check battery Feel: box hot? if so may be thrombosis
Abx a/w development of infantile hypertrophic pyloric stenosis
MACROLIDES
OM with posterior ear pain -mcc: acute vs chronic -NBS -Tx
MASTOIDITIS -mcc: acute = *Strep pneumo (same as OM)*; chronic = Pseudomonas -NBS: Dx w/ *CT scan* -Tx: IV Abx & ENT consult
COPD related arrhythmia - think? Tx?
MAT; Tx: IV Mg arrows point to different P wave morphologies
unhappy/O'Donahue/terrible traid -cause
MEDIAL MENISCUS ACL MCL -caused by lateral force to knee when foot is planted (RB getting tackled)
diff b/w LEMS & MG
MG has ocular involvement, worse with repetition LEMS improves with repetitive activity both have prox mm wknss with DTR maintained
NEXUS criteria
MIDL-F (middle finger) Midline TTP Intoxicated Distracting Injury LOC/AMS Focal Deficits
Kayexylate: MOA? c/i in?
MOA: binds K, release Na into blood steam c/i: CHF (bc will take on more fluid)
wood in eye not seen on CT - NBS typhoid fever transmission
MRI; obviously don't do if concern for metal person to person (ie fecal-oral route)
rash on hands think
MRS TECK Meningococcemia, RMSF, Syphilis/SKS Toxic shock syndrome/TEM, Endocarditis Cox A (HFM Dz), Kawasaki
ciguatera mis-Dx as
MS
u/l or b/l parotid gland swelling - think -T/F: any salivary gland can be affected - not just parotid -cp -comp -Tx/prog
MUMPS -T: any salivary gland -cp: swelling 2+ d w/o apparent cause -comp: epipdidymo-*orchitis* (typically *u/l*) -Tx: supp; prog: resolves in 1 wk
mid systolic click think
MVP
Mallory Weiss vs Boerhaave tears -thickness? -loc? -cp
MW: -partial -@ G-E jxn -forceful vomiting --> bleeding from *submucosal aa.* B: -full thickness -@ L postero-lateral wall of *distal* esoph (that region is unsupported) -post emetic *chest pain w/ htn*
shoulder dystocia - NBS
McRobert's Maneuver 1) Pt: in extreme lithotomy position (legs spread & back) 2) You: apply suprapubic P to push shoulder down
How to differentiate Mobitz II vs Complete
Mobitz II: R-R interval are irreg complete heart block: *P-R intervals are irreg* (P-P & R-R are regular)
2 main forearm Fx
Monteggia & Galeazzi GRUM or *GRIMUS*: tells you which bone is Fx and whether distal ("inf") or prox ("superior") part involved. G: Galeazzi, R: radius, I: inferior M: Monteggia, U: ulna, S: superior *dont forget about corresponding disloc!!!*
severe sinusitis form in DM Pt -cp -Tx-
Mucormycosis -thick black nasal discharge -Tx: ampho B 1 mg/kg
cardiac biomarkers: Mb, trop, CK-MB - pro vs con
Myoglobin: earliest detection (2-3 hrs); poor SP trop: highest SP, rises w/in *6 hrs*; elevated for *1-2 wks* so *bad in case of re-infarction* CK-MB: close SP to trop, *only elevated 1-2 days* so *good for re-infarction*
c/i Rx in preg
NAT SAFE WoMAn -*N*SAID, *A*CEi, *T*etracycline -*S*ulfonamides (TMP-SMX), *A*SA, *F*luoruoquinolones, *E*rythromycin (macrolides) -*W*arfarin, *M*ost *A*nticonvulsants
chemical burns to eye - NBS? which worse?
NBS: irrigate obv alkali (liquefactive necrosis) > acidic (coagulative necrosis) bc LIQUEFACTIVE HAS DEEPER PENETRATION
broken nose suspected - NBS septal hematoma mgmt? comp if not Tx?
NBS: no imaging. r/o assoc injuries to orbit/midface. if only nasal fx --> ENT f/u as out-Pt in 3-7d (gives time for swelling to come down before doing closed rdxn) mgmt: I&D. pack for 2-3d, refer to ENT for packing removal; if not Tx'd: hematoma prevents septum perfusion --> weakened septum --> collapse of nose --> *saddle nose deformity*
neonate w/ history of prematurity p/w poor feeding, vomiting, distention & *(+) FOBT* -#1 rFx -Dx -Tx
NEC: Necrotizing Entero-Colitis -XR: air in bowel wall = *pneumatosis intestinalis* -Tx: Abx, surg
top 3 mcc of meningitis in order in the following groups: neonates, infants/kids, teens, adults
NEONATE: GEL (GBS, E. Coli, Listeria) Infants/PEDS: S. pneumo, N. mening, H. flu Teens: N. mening, S. pneumo Adults: S. pneumo, N. mening, Listeria
THIRD
NEURO
food impaction Tx choices
NG, glucagon (both relax LES)
OB/GYN
NO 7
#1 thing to rmr with decompensating Pt w/ LVAD who is in VT on monitor and w/o pulse
NO CPR!!!!!!!!! they may not have a pulse. that's normal. give *IVF and consider dobutamine if R-sided HF* can *shock* as long as leads dont touch device. JUST *NO CPR*
this sedative can expand the size of a PTx while placing a chest tube
NO: it's a gas so can expand if chest tube not in place
AG
Na - Cl - HCO3 *CAT MUDPILERS*: -CO, CN, CHF; Aminoglycosides; Toluene, Theophylline -methanol/metformin, uremia, DKA (also AKA or starvation), Paraldehyde, Iron/INH, LA, EtOH/Ethylene glycol, Rhabdo, ASA
No IVIg for Tx req big 3 for Tx (IVIg, plasmapharesis, CS) GBS Tx
No IVIg: botulism (needs anti-toxin) & tick (remove) big 3: MG & LEMS GBS: IVIg & plasmapharesis (no CS)
oxygen delivery mediated by?
O2 delivery = DO2 = [O2] delivered to capillaries/min DO2 = CO x CaO2 (mL/min/m2) CaO2 = (1.34 x *Hb x SaO2*) + (0.003 x *PaO2*) DO2 = *CO* x (1.34 x *Hb x SaO2*) + (0.003 x *PaO2*) oxygen delivery can be affected by changes in (4): -cardiac output -O2-sat: amt that O2 can be saturated on Hb molecule -[Hb]: amt of total Hb available -PaO2: *to a much smaller extent* (amt of O2 dissolved in blood) when Hb is completely saturated with O2 (ie SaO2 is 1.0 or 100%), increases in the PaO2 have a *negligible impact* on the CaO2 and oxygen delivery.
orbital cellulitis vs periorbital (preseptal) cellulitis -pp -mcc/cx pe -Tx
OC -pp: *direct spread* of adjacent infxn (sinusitis) --> into orbital septum and *NOT face* -pe: *proptosis, painful EOM, decr vision* -Tx: IV Abx POC -pp: *local spread* via scratch/insect bite --> eylid infxn (superficial) *W/O* extension to orbital septum -mcc: Staph, GAS, strep pneumo -Tx: PO augmentin
10 d/o with peri-umbilical swelling, erythema & drainage at stump site w/o fluctuance or fever - think -what is it -NBS -why -mcc
OMPHALITIS -superficial cellulitis of umbilical cord -NBS: *b-s IV Abx* & *consult peds surg!!! bc...* -be aggressive bc *can progress to nec-fasc*. most will present w/o fever and once they come w/ fever, nec-fasc is already there -mcc: polymicrobial (hence covering broad-spectrum ie staph, pseudomonal, anaerobic)
HEME
ONC & RHEM
FIRST
ORTHO
if SCFE and LCPD are confused, and transient synovitis & septic arthritis are confused, which L/E PEDS entity sits by itself? -clin pres -laterality? -Tx
Osgood Schlatter -focal ant knee pain *@ tibial tuberosity in < 19 y/o* 2/2 apophysitis (inflm of patellar ligament @ tuberosity bc of overuse) -BOTH: can be b/l -NSAID & rest
Parkinson mnemonic
P is a set of *TRAPS*/makes sure you *STRAP* up: *T*remor (pill rolling, at rest) *R*igidity (cog wheel) *A*kinesia - inability to initiate a movement *P*ostural instability (difficulty w/ balance) *S*huffling gait pp: reduced DA-R in substantia nigra ALI is a Substantive Negro who had to STRAP/watch out for a set of TRAPSa
pertussis PEP? meningococcemia PEP?
P: *Z-pak* (give to *all household contacts*) M: *1 x cipro 500 mg* or *1 x rocephin 250 mg IM*
paronychia vs felon -location -bug
P: think *P*eripherally around nail fold (dorsal); S. aureus; term-94 F: think *F*leshy pulp of finger (palmar); S. aureus
HLA B27 seronegative arthropathies
PAIR: Psoriasis, Ank-Spond, IBD, ReA
Tetanus Tx -mcc death?
PCN + benzo (for spasticity) -sk mm spasm of resp tract
vertical nystagmus think phenytoin toxicity Tx
PCP phenytoin tox: multi-dose activated charcoal (*T's*)
mc site of esoph FB entrapment: kids vs adults
PEDS: @ *cricopharyngeus mm.* @ *C6* ADULTS: @ *LES* @ *T10*
how to tell whether jaundice in neonate is physiologic or pathologic
PHYSIO: develops w/in *1st wk* of life; lasts *< 2 wks* -mcc: immature liver PATH: develops w/in *1st day 24 hrs*; lasts *> 2 wks*
profuse threatening hemorrhage w/ attempted manual placental separation during delivery -pp -Tx
PLACENTA ACCRETA -pp: Pt has overly adherent placenta so it *over-implants into uterine wall and becomes one with it* -*planned pre-term cesarean hysterectomy* w/ *PLACENTA LEFT IN SITU* (bc attempts at removal will just lead to possibly fatal hemorrhage)
pain*less* 3rd trimester vaginal bleeding -think? -pp -rFx (5) -classic cp -comp
PLACENTA PREVIA -pp: ab-NL implantation of placenta (*covers os*) -rFx: multiparity, advanced age (same 2 as previous) + *previous uterine surg* -*sentinel bleed @ 1st* followed by more significant bleeding days to weeks later
when to place a magnet over a PPM vs ICD
PM: reprograms pacer to asynchronous mode (constant pacing delivered regardless of native rate); will *NOT* turn it off ICD: magnet *WILL* inactivate it; do when Pt getting inappropriate shocks, if you're transQ pacing, if fam wishes to stop resusc efforts
when to choose oral vs IV rehydration
PO (3): delayed CRF, dry MM, decr tear prod IV (3): skin tenting, sunken fontanelles, lethargic
knee dislocation - biggest concern?
POPLITEAL ARTERY INJURY (& to lesser extent peroneal/fibular n. injury)
when is risk of thromboemoblism highest in preg
POST-PARTUM PERIOD
best clinical way to diff PTA from pharyngitis/tonsillitis
PTA has TRISMUS
main diff b/w pemphigus vulgaris & bullous pemphigoid
PV = (+) Nikolsky = more severe form -pemphigu*S = S*uperficial *B*P = (-) = @ *B*asement membrane -pemphigoi*D = D*eep
*NON*-bilious projectile vomiting in neonate is this until proven otherwise - think -cp: -Cx pe -NBS if suspected -A/B d/o
PYLORIC STENOSIS -5 w/o (*<3 mos*) w/ non-bilious projectile emesis who has FTT -*olive shaped palpable mass* -if mass felt, call surg; if no mass = *US* -vomit = loss of acid/HCl = *met alk, hypoCl & hypoK* (loss of Cl- is obvious, loss of H+ --> loss of K+)
PaO2 vs. SaO2 vs. SpO2 vs. HbO2
PaO2 = pressure the *dissolved oxygen *exerts on the artery - units: mmHg (torr) - will detect hyperoxemia SaO2 = % saturation of O2 on Hb as *CALCULATED *from measured PaO2 - units: % - since it is calculated, it assumes there is no abnormal forms of Hb (ie COHb, MetHb) SpO2 = % saturation of O2 on Hb as *MEASURED *using *pulse oximeter* - units: % - since non-invasive, does not register abnormals HbO2 = % satuation of O2 on Hb as *MEASURED *using *co-oximeter* - units: % - since it is measured, it is *more accurate *& takes into account abnormals (ie COHb, MetHb)
mother reports child has been scratching his anus - think -SN test/NBS -Dx -Tx ^note abt Tx
Pinworms (Enterobius) -*scotch tape test*: scotch tape to anus, pull it off, look for worms -Dx: stool O/P not helpful bc pinworm not shed in stool -Tx: *single dose mebendazole or pyrantel* ^Tx all family members too!
main comp of sinusitis -other comp
Pott's puffy tumor: sub-periosteal abscess a/w osteomyelitis of frontal bone -meningitis, brain abscess, *cavernous sinus thrombosis*
silvery scaly plaques on erythematous base -loc -a/w Cx finding -Cx pe sign -Tx -a/w this random Dz
Psoriasis -*extensor* surface -Cx: *nail pitting* -*Auspit'z sign*: punctuate bleeding spots when scales peeled off -Tx: topical CS, *MTX*, tar, UV light -a/w: *CVA*
hand nerves
RADIAL: DORSAL MEDIAN: PALMAR ULNAR: both sides DR PM think of letter U swinging to both sides
expected LP findings in SAH?
RBC = *xanthochromia* = yellow CSF 2/2 bili real Q is differentiate traumatic tap from SAH. do this by: *see how many RBC's are in tube 4 (ideally last tube drawn)*. it's not enough to just approximate 0 RBC, *you need to actually have 0 RBC to r/o SAH*
SNAKE SONGS to RMR
RED TOUCHES YELLOW/KILL A FELLOW (pic) RED TOUCHES BLACK/FRIEND OF JACK
US more SN than XR for which fx
RIBS
Tb Tx & their A/E
RIPE for Tx -Rifampin: red/orange body fluids, hepatitis -INH: *I*njures *N*eurons & *H*epatocytes = peripheral neuropathy (needs vitB6/pyridoxine), hepatitis -Pyrazinamide: hepatitis, hi uric acid -Ethambutol: optic neuritis also streptomycin: nephro/oto-toxic (amiNOglycoside)
high fever --> defervescence --> new onset rash - think? -mcc
ROSEOLA INFANTUM (exanthema subitum) -HHV-7 & 8 (human herpes virus)
5 y/o w/ fever & sore throat & post pharyngeal edema - think -mcc -diff from PTA -Dx - BI vs MA -diff from epiglottitis -Tx
RPA (retropharyngeal abscess)- -mcc: *polymicrobial* -PTA in younger adults (13-25), this in 5 y/o or less -BI: lat neck XR; MA: CT w/ -epiglottitis is more rapid course, this is slower -Tx: *ENT consult for I&D*
RUBELLA vs RUBEOLA -aka -Cx sx
RUBELLA (GERMAN MEASLES aka '3 day measles') -triad: fever, rash, *lymphadenopathy* -instead of Koplik spots, has *Forchheimer spots* (rose colored spots on *soft palate*) RUBEOLA (MEASLES) -tetrad: *4 C's* = cough, choryza, conjuntivitis & (C)Koplik spots (on *buccal mucosa*; white or blue spots on red base)
most SP finding of tamponade on echo
RV diastolic collapse 2/2 effusion
C. perfringens vs S. aureus food poisoning
S. aureus begins w/in 1-6 hrs - resolves by 6-8 hrs C. perfringens begins 6-12 hrs after exposure
mcc of PNA in HIV
S. pneumo - *NOT* PCP
Safe vs Unsafe vaccines
SAFE: these ones are *RI*g*HT* to take -Rabies, Influenza, g, HepB, Td UNSAFE: "MMM... no" *MM*R
mcc SBO mcc LBO
SBO: adhesions LBO: cancer (pictured)
spinal tracts
SENSORY/ascending -*ALS* (anterolateral system aka spinothalamic tract): *PTt* (Pain, Temp, crude touch) -*DCML* (Dorsal column-medial lemniscus): *PVT* (Position, Vibration, fine Touch) MOTOR/descending -*lat*eral *CST* (cervical medial, lateral sacral) -*ant*erior *CST* (corticospinal tract)
must rule out this when considering fever + limp -mc bug -how to Dx
SEPTIC ARTHRITIS -S. aureus (BCx only (+) 50% of time) -needle aspiration (usu done by IR)
painful vesicles in a dermatoma distribution -pp -Tx -severe form?
SHINGLES (ZOSTER from V*Z*V) -pp: VZV reactivation from previous varicella (chicken pox) --> Cx rash in dermatome -Tx: acyclovir -disseminated zoster: rash in 3 or more dermatomes (sign of i-c Pt)
shoulder vs hip - which dislocation mc
SHOULDER: ANT HIP: POSTER --> shortened, int rot, adducted (so ant is ext rot and abducted)
SIADH vs Diabetes Insipidus: serum Na/osm, urine Na/osm
SIADH: serum Na/osm *DECR*; urine Na/osm *INCR* DI: opposite (no ADH --> no water absorption into systemic circulation --> water floods collecting system --> urine Na/osm decr & thus serum concentrates/incr) IMP: *think of SIADH 1st*, then DI as the opposite. problem w/ ADH (ie decr ADH efficacy - CNS vs renal)
mcc of mortality in infants in US -rFx -home monitors help
SIDS: sudden infant death syndrome -rFx: *smoking during preg*, *low maternal age*, lack of prenatal care, PTL, *sleeping prone* -NO. home monitors *do not* help
-Rotator cuff mm SITS - attach where?
SIT attach at greater tuberosity of humerus; Subscap to lesser tuberosity
rotator cuff mm.
SITS Supraspinatus Infraspinatus Teres Minor Subscapularis
NEPHRO/GU
SIXTH
diffuse epidermal necrosis & detachment - think -mcc -cp -pp -comp -mc death
SJS/TEN (San Jose State minor league < 10, TEN > 30) -Rx-induced: *allpurinol, sulfa, PCN, phenytoin* -cp: fever w/ flu-like Sx --> skin blisters w/ *MM involvement* -pp: epidermis separating from dermis (hence +Nikolsky) -comp: *permanent vision loss* so consult ophtho -death: sepsis 2/2 pseudomonas vs MRSA
CHF: most SN vs SP finding
SN: DOE SP: in Hx = PND, on PE = S3 gallop
mc injured organ in BLUNT abdominal trauma
SPLEEN blu*N*t, splee*N*t or nothind BUNDT cakes is SWEET/SPLEEN
SS vs NMS -how to diff
SS: Serotonin Surge - Super Sprightley -more acute in onset -tremor and hyperreflexia (hyperactivity) NMS: No More Shit - burned out, relaxed -takes days to weeks -'lead pipe' rigidity (hypoactivity); if anything hypo-DTR *If Pt taking both Rx*: incr in CK, LFTs & WBC W/ *low iron level* = NMS
recurrent hypoglycemia (after you Tx in the ED) - think tox of this Rx
SULFONYLUREA = *SU*stained = glyburide, glipezide
facial swelling (+ periorbital edema) w/ SOB think -BI Dx -MA Dx -mcc cause; a/w
SVC syndrome -BI CXR: look for mass compressing SVC -MA: CT w/ -mcc malignancy: *SmCC* --> neoplastic syndrome (*SIADH*) --> low serum osm/hypoNa, hi urine osm
loose watery stools that happen to be FOBT -a/w
Salmonella (think salmon in water) -assoc w/ pet turtles & eggs
Pt w/ hx dysphagia of solids with liquids later w/ new food impacted bolus - think -def'n -MA Dx test -a/w
Schatzki Ring -ring of mm. tissue in esophagus -Dx with *upper endoscopy* -a/w hiatal hernia
scromboid & ciguatera (fish poisoning) -causes -pp -cp
Scromboid -mcc: tuna, mahi mahi -pp: *histamine-like toxin* -cp: *rapid Sx onset (w/in 30 mins) = facial flush, palpitations* + GI Sx diarrhea, ab cramps *C*iguatera (think *C*NS) -mcc: barracuda, red snapper -pp: neurotoxin -cp: GI Sx (N/V/D) *followed by NEURO Sx (HA, numb, PARESTHESIA, ATAXIA, COLD-HOT REVERSAL)*
carpal bones
So Long To Pinky (bottom row) Here Comes The Thumb (top row) scaphoid, lunate, triquetrum, pisiform hamate, capitate, trapezoid, trapezium
aka Rose gardener's disease -cp -Tx
Sporotrichosis -cutaneous ulcers along lymphatic channels -oral fluconazole, potassium iodide
APAP toxicity: 4 stages of Sx
Stage 1: N/V Stage 2: N/V stops; *hepatic/renal dysfxn starts* Stage 3: *LFTs peak*, ARF, *encephalopathy, DEATH* Stage 4: *recovery IF you survive* stage 3
measles 10 yrs before --> now AMS - think
Subacute sclerosing panencephalitis (SSPE) - prog degen dz of CNS
longest acting oral hypoglycemic you worry about in overdose -Tx?
Sulfolynulreas: Glyburide, Glipizide bc *long t-1/2: 12-24h* so may get *recurrent hypoglycemia* so ADMIT! -def Tx: *octreotide* (somatostatin)
GHB (gamma hydroxybutyrate) mainly used for -Cx Sx
Surreptitious drugging to facilitate sexual assault -period of agitation/flailing alternating with resp depr = "drowning swimmer fighting for air"
why does Sux lead to more rapid desaturation than Roc
Sux induces fasciculations which causes incr oxygen use and hence more rapid desat
bad RSI Rx in MG
Sux: binds to ACh-R (agonist) but MG destroys ACh-R so more circulating Sux. now you need higher doses than normal and run risk of prolonged paralysis applies to *both depolarizing & non depolarizing agents*
most difficult salter harris to see
T1 vs T5: XR often neg T1: look at lat films for actual side slippage/no alignment T5: look for lack of growth plate due to compression (~ to torus/buckle but @ physis)
HS types mnemonic
T1: A = Allergy/Anaphylaxis T2: B = anti-Body T3: C = immune Complex T4: D = Delayed
T/F: in SS, Pt could be taking Rx for years w/o Sx T/F: SS involves OD component dantrolene used in? MOA?
T: and once new med is added on - boom --> SS F: nothing to do with overdose/tox dantrolene: in NMS and MH (both have rigidity but NMS is lead pipe, MH is not; blocks Ca release from SR --> no sk mm Cx --> sk mm relaxation)
T/F: PO Abx not indicated for known, vaccinated dog bite
T: just keep it moving for cat/dog, only hi risk get Abx: dirty wounds, lac to hands/feet (where its avascular), deep wounds (mm./tendon/bone or joint capsule), i-c Pt, wounds associated with significant local edema
T/F: trich is asymptomatic 70% of time MCC of vaginal d/c how does candida albicans pH differ from BV/trick
T: mostly in M tho MCC: BV candida pH 3.8-4.5 (more acidic)
T/F: do nothing for TM perforation ^ exception barotrauma related cases
T: no Abx nec. just avoid water getting in. Abx only if perf is 2/2 infxn or water gets in baro: can be from high altitude (decr P but incr V) or low altitude (diving with incr external P)
T/F: compartment P can be < 30 if hypotensive T/F: elevating affected leg above heart is part of mgmt
T: rmr delta P (diastolic - compartment P) if DBP goes from 80 to 40 and compartment P stays at 20, you go from 60 to 20 (<30 is concerning). F: keep AT level of heart. if you go above, decr arterial flow --> exacerbates ischemia to area
T/F: kidney injury can p/w w/o hematuria
T: so dont wait for UA
T/F: subluxation of C2 on C3 is a normal anatomic variant in kids?
T: up to 20% of time hence the term "pseudo-subluxation"
Thromboangiitis obliterans (Buerger disease) vs Takayasu's arteritis -pp, cp
TAO -pp: AI; cp: *middle aged Azn M* w/ chronic vasculitis of *hands/feet* (ie *Raynaud's*) TAKAYASU -pp: AI; cp: young Japanese F w/ chronic vasculitis of *aorta* --> pulseless extremities
only antidote to toxicity that requires alkalinization of blood - not urine - think? -MOA -pp -Tx
TCA: Tricyclic Antidepressants -MOA: *sodium channel blocker* so slows phase 0 of cardiac action potential --> widen QRS -Pt has acidemia bc combo acidosis: resp depr --> *resp acid* + myocardial impairment --> htn --> LA/met-acid -Tx: *blood alkalinization w/ sodium bicarb* - increases sodium (since it's blocked), neutralizes acidemia
Dx test of choice for unstable suspected aortic dissection #1 rFx for dissection vs AAA most SP sign on CXR
TEE rFx: chronic HTN for dissection; smoking for AAA CXR: extension of aortic shadow > 5 mm past calcified aortic wall (more specific articulation of widened mediastinum)
ENVIRONMENTAL
TENTH
main fungal infxn (5)
TINEA: versicolor, capitis, cruris, pedis, corporis,
Pt yawning and now jaw stuck open - think? mc type?
TMJ dislocation; disloc = *anterior & bilateral*
neck trauma zones
TOP DOWN 3: angle of mandible UP 2: *cricoid cartilage to angle of mandible* 1: cricoid cartilage down
Pt recv blood transfusion becomes acutely SOB, hypoxic. stat CXR shows diffuse b/l infiltrates - think? -NBS?
TRALI: TRansfusion associated Acute Lung Injury -NBS: *wont respond to diuresis* so stop transfusion and give supp O2
MCC of painful hip + limp in kids -first thing to check -imp in Hx -must r/o -best imaging -Tx
TRANSIENT SYNOVITIS (inflm of synovium) -does Pt have a *fever*? not 100% but good to ask -Hx: *recent viral infxn*, trauma or vaccine -r/o *septic arthritis* so ck CBC, *ESR*, CRP -XR normal but *US* can show *hip effusion* -NSAID
SECOND
TRAUMA
bacterial vaginosis vs trich -cp -spread by? -Dx -Tx -pH
TRICH -cp: sharing razor w/ bf & now has *green smelly d/c & cervix looks like strawberry* (Red, Green, Xmas Tree/Trich) -spread by sex -Dx: motile organism -oen dose *metro 2g* -pH: > 4.5 BV -cp: thin, *white d/c with fishy odor* - *NOT considered true STD* but overgrowth of nl vag flora -spread by sex; Dx: *clue cells* (epith cells coated w/ bact); Tx: topical azoles or oral flagyl 7d; same pH
T/F: CT scan has NO ROLE in r/o epidural abscess
TRUE
T/F: airbag deployment confers no additional preg-related risks to mom in MVA
TRUE
T/F: compartment syndrome can occur with open fx
TRUE
T/F: even w/ mild placental abruption, some fetal distress is present
TRUE
T/F: paraphimosis can be d/c home if able to void?
TRUE
T/F: in acute dig toxicity, the degree of hyperkalemia correlates w/ mortality
TRUE low K makes you most susceptible to the toxic A/E hi K means greater (P) you die!
T/F: the heigh of the Osborn wave is proportional to degree of hypothermia -pp -c/i
TRUE -slow pacing --> diffusely prolonged intervals -c/i: *pacing --> VF* (so address the hypothermia and warm the Pt)
T/F: LVAD Pt can be in VT/VF while awake and w/o Sx
TRUE!!!!!!
T/F: For mushrooms, vomiting early is GOOD
TRUE: *delayed onset is bad = Amanita = hepatotoxic* -if Sx acute (ie < 6 hrs), ingestion unlikely to be toxic
T/F: anti-motility agents can be used BUT ONLY in combo w/ Abx for traveller's diarrhea
TRUE: but no-no in bloody, invasive diarrhea
T/F: most neonates born w/ congenital CMV are asymptomatic
TRUE: but rapidly evolve into not being able to see or hear (*C*horioretinitis, *M*ute/*deaf*, li*V*er = jaundice, hepatomegaly) Tx: IV ganciclovir
T/F: you don't need an APAP level to start NAC
TRUE: checking a level *prior to 4 hrs* is *NOT* helpful Tx w/ NAC is just as effective if you start at 1 hrs or 7 hrs post ingestion. just needs to be started *w/in first 8 hrs*
T/F: in wellen's trop are neg
TRUE: ecg findings are not yet STEMI bc there is spontaneous, temporary re-perfusion of occluded LAD
T/F: acalculous cholecystitis has a higher mortality rate than calculous cholecystitis
TRUE: found more in elderly, ICU Pt, HIV Pt
T/F: give tetanus prophylaxis even to those who present late (ie > 24 hrs) after laceration?
TRUE: incubation period can take months
T/F: 33% of all occlusive arterial Dz is 2/2 reperfusion injury
TRUE: look for myalgia, swelling, hi CK, hyperK, ARF
T/F: Pt who smoke can have a baseline CO level of 10% T/F: pe will show cherry red skin/lips in CO poison T/F: HBO lowers mortality of MI
TRUE: non-smokers have baseline CO level of 3% FALSE: pe typically unremarkable, usu changes in AMS FALSE: does NOT decr risk of MI/arrhythmia
T/F: Abx have no benefit in treating invasive diarrhea of healthy no i-c Pt
TRUE: only Tx if *severe sx* (severe diarrhea/dehyd, high fever, need hospitalization w/ *3-7d Abx = cipro, bactrim or amox*)
T/F: coag abnormalities are not seen in HELLP
TRUE: stick to the name
T/F: syphilis can be (-) 4-6 wks following infxn Jarisch-Herxheimer rxn: what is it? NBS? T/F: 2º syphilis Pt always report having a chancre syphilis Tx alternative for PCN allergy
TRUE: takes while to be (+) J-H rxn: acute febrile rxn to PCN w/in first 24 hrs (Abx releases toxin); NBS = Tx w/ *Tylenol* F: most say they never had chancre alt: if preg, *desens & STILL PCN*; if *not preg, DOXY (preg class D)*
T/F: CO & CN are clinically indistinguishable CN Cx pe T/F: you can check a CN level to r/o CN tox CN Tx
TRUE: they're the same CN: smell for *bitter almonds* F: look for *severe, refractory met-acid w/ hi lactate ~ 8 & large AG* (bc it inactivates *Mt ox-phos*) Tx: HYDROXY*C*OBALAMI*N (CN)* + SODIUM THIOSULFATE (backup amyl & sodium nitrite)
T/F: SDH mc than EDH with higher mortality rate
TRUE: think subdural is harder to evacuate bc you have to get past meninges (dura) and the patients are usually baseline less healthy
T/F: timolol can cause heart block
TRUE: use with caution
T/F: dog bites ok to close with sutures
TRUE: you've done it
tarsal tunnel syndrome - involves what & when felt Sever's Dz - aka? clin pres? cause? Tx? Plantar Fasciitis - clin pres? when felt? Tx?
TTS: posterior tibial n. entrapment neuropathy; think nocturnal neuropathy S: aka calcaneal apophysitis; adolescent w/ non-traumatic heel pain; 2/2 growth plate expansion; NSAID PF: sole pain from overuse; worse in morning (w/ "1st steps of day"); Tx: rest, NSAID
Td or Tdap?
Td: if > 65 or never gotten Tdap before Tdap/Boostrix: never received Tdap prior Past vac unknown or <3 total -Clean wound → Td -Dirty wound → Td & TIG Past vac 3 or more total -Clean wound → Td Q10yrs -Dirty wound → Td Q5yrs
most severe/unstable cervical fracture -cause -why so bad -cause
Teardrop fracture -fx of the ant-inf aspect of a C5/C6 2/2 *flexion* -cause *anterior cord syndrome/quadriplegia* -severe flexion --> compression at C5/6 (think diving into a shallow pool head first)
MA method of determining if Pt needs transfusion s/p trauma? -what is it? why to do it -how it's done
Thromboelastography (TEG) -used to ID *acute coagulopathies* in both traumatic and nontraumatic Pt to help find out *whether Pt needs and which blood products best during resuscitation.* Quantifies interaction of PLT w/ Coag Cascade (aggregation, clot strengthening, fibrin cross linking and fibrinolysis). 0.36mL of clotted blood from Pt spun in a small cup with changes in the clot strength recorded electrically.
anterior mediastinal mass DDx? mcc?
Thymoma (MG) Thyroid T-cell lymphoma Teratoma Terrible (*bronchogenic carcinoma = mc*)
CNS mass lesion in HIV Pt -Dx
Toxoplasmosis -CT *w/: ring-enhancing lesion*
IE Tx IE Px: what procedures & what Rx
Tx: vanco Px: 1 dose *2g PO amox* for *dental cleaning, bronch (rigid), cystoscopy*
Cx EKG for hypokalemia
U wave need to bring the K+ *U*p
ROM and you do pelvic exam and feel presenting part -NBS(s) (ie STEPS)
UMBILICAL CORD PROLAPSE -prep for emergent C-Sx generally but specifically: 1) Do *NOT* attempt to reduce cord 2) *place Pt in Trendelenburg (knee-chest)*, encourage not to push or cough (incr ab P will worsen prolapse) 3) insert *sterile gloved hands and push/elevate presenting fetal part away from prolapsed cord* to reduce compression and... (rmr whoever Dx'd umbilical cord prolapse must maintain decompression until in OR) 4) transport to *OR for emergent C-Sx*
1 wk hx renal transplant with oliguria and ARF - NBS
US: r/o *lack of blood flow* - may need surg exploration to salvage allograft vs *fluid collection* to r/o urinary leak no need for CT or MRI, we only care about *fluid* here
nystagmus sign concerning for central veritgo peripheral vertigo mnemonic
VERTICAL NYSTAGMUS *HINT* about peripheral vertigo: Horizontal-rotational nystagmus Intermittent Sx, Immediate sudden onset, Intense pain Nausea Tinnitus
young pitcher playing baseball w/ no hx heart Dz gets hit in chest with baseball --> codes - think?
VF 2/2 blunt cardiac injury = *commotio cordis*
EKG with wide complex, irregular tachycardia - think?
VF, AF w/ BB, *AF w/ WPW* Tx: procainamide
vestibular neuritis vs labyrinthitis triad of Meniere's Dz? Tx? aka?
VN: auditory fxn is preserved; post-viral L: hearing loss triad: hearing loss, vertigo & *tinnitus*; Tx: low-salt diet, HCTZ; aka idiopathic endolymphatic hydrops
watery diarrhea match: VCGC -a/w raw oysters -rice water -mountain stream -AIDS Pt
Vibrio, Cholera, Giardia, Cryptospor -raw oysters specifically: Vibrio (vulnificus if skin, para if not) -rice water diarrhea: cholera -stream: giardia (2 wk water, steatorrhea) -AIDS: cryptospor
septic joint arthrocentesis labs
WBC > 50K PMN > 50% Cx (+) LOW GLU < 25 rmr *> 50*
what type of foreign body you step on warrants emergent removal
WOOD: incr risk of infxn (> metals, glass, plastic)
BILIOUS VOMITING IS ALWAYS
WORRISOME and therefore *always volvulus w/ malrotation in neonate until prover otherwise*
dysphagia w/ Horner syndrome & PTt loss - think
Wallenberg's Syndrome
child running with popsicle stick in mouth falls and it penetrates roof of mouth - NBS? consider? comp?
XR neck: r/o free air vs foreign body -consider *angiogram* (jugular & carotid aa. nearby) if *persistent bleeding or hematoma* -comp: 2º infxn (ie *RPA*)
is round pneumonia an actual thing in PEDS? -DDx -why -mcc
YES -Tb, fungal infxn, aspergilloma, abscess -d/t anatomy: seen in superior segments of lower lobes -mcc: Strp pnae
proximal humerus fracture - ck this
a*X*illary n. for pro*X*
what is a molar preg in basic terms
ab-NL pregnancy 2/2 ab-NL fusion of sperm & egg. instead it grows into a uterine mass w/ swollen, clusters of chorionic villi (~ grapes). 2 types: -complete molar preg: fetus does *not* develop at all. 90% result from the duplication of a sperm that fertilizes an *"empty" ovum* (So maternal Chr absent). other 10%: fertilization of empty ovum by 2 diff sperm -partial: fetus develops but will be ab-NL bc it carries 'triploid' genotype (XXX or XXY) bc the fertilization of a normal ovum is done by *two sperm*.
2 main thumb ligaments -over use of this is called -clin test -Tx
abductor pollicis longus extensor pollicis brevis -DeQuervain's Tenosynovitis -Finkelstein's test: make Fist, ulnar deviate, (+) = pain -Tx: splint, NSAID
Rx potency measured by incr [Rx] vs changing Rx altogether - better method to reach desired potency & why
ability to induce v/c change Rx and give gaps - otherwise tachyphylaxis
most SN clin test for carpal tunnel
abnormal sensation of distal tip of index finger (NOT Tinel's/Phalen's)
sciatic n. assoc w/ which 2 injuries
acetabular fx (break in the socket portion of the "ball-and-socket" hip joint) + posterior hip dislocation
red eye worsened in dark room - think -assoc Sx -pe -Tx
acute angle closure glaucoma -assoc w/ *ab pain + N/V* -pe: hazy cornea, *fixed dilated pupil, incr IOP* (nl 10-20) -Tx: *STAMP* = Supine, Timolol eye drops (c/i COPD), Acetazolamide, Mannitol 1-2g/kg IV, Pilocarpine drops
Pt was in endoscopy and immediately after getting benzocaine spray --> acutely cyanotic - think -pp -cp -labs -mcc
acute onset cyanosis - think *Methemoglobinemia* -pp: Hb alters as ferrous (Fe2+) ions --> ferric (Fe3+) which now *cant bind O2* = fxnal/*qualitative anemia* -cp: blue appearing Pt w/ *choc brown blood* -Dx: H/H will be normal, hence "functional anemia" -mcc = *Rx* = lido, dapsone, *benzocaine spray*, inh NO, sulfonamides, *pyridium* (why it's only Rx for 2d), nitrate additives (sausage)
types of SDH (subdural hematoma)
acute: white (w/in 3 days) subacute: same color (3d-3w) chronic: black (> 3 wks)
preferred IO line - adult vs PEDS
adult: prox humerus - 2nd fastest rapid infusion rate after sternum peds: prox tibia bc most easily palpated
mcc of meningitis in adults mcc of meningitis in teens (adolescents/young adults) mcc of meningitis in neonates
adults: STREP PNEUMO teens: N. MENINGITIDIS neonate: GBS
meningitis Tx for: adults, > 50 y/o, neonates
adults: vanco + ceftriaxone/rocephin (Vince Carter) > 50: add ampicillin for Listeria neonates: ampicillin + gentamicin/cefotaxime amp 50 mg/kg, cefotaxime 50 mg/kg
best ACLS tactic in hypothermic Pt hypothermia assoc arrhythmias
aggressively rewarm the patient arrhythmias: brady, AF
Takotsubo: aka, what is it
aka broken heart syndrome; non-ischemic CMP w/ sudden rdxn in EF 2/2 emotional event
sucking chest wound - aka? Mgmt?
aka open PTx: *three sided occlusive dressing* (from petroleum gauze): prevents air from entering during insp, but can leave during exp via 1 way valve
FOOSH fractures (3) & their mgmt
all are *DISTAL RADIUS Fx* but w/: 1) Colles Fx: w/ dorsal displacement (Tx: rdxn) 2) Smith Fx (reverse Colles): w/ volar/plantar displacement (Tx: rdxn) 3) Barton's Fx: w/ disloc of radio-carpal joint (Tx: surg)
negative Babinski
all toes plantarflex (downward) if (+) big toe goes UP to head (rmr UPper motor neuron lesion) and other toes fan out
jelly fish sting. NBS? for Portuguese man of war (~ jelly fish) - how diff? NBS? for sting ray or coral sting - NBS?
almost identical to above! 1) remove tentacles with tweezers 2) apply *vinegar or acetic acid* vigorously - then soak it in vinegar for 30 mins 3) soak in *hottest possible water* PMOW: sting in whip like fashion on top of foot, not sole; NBS: hot water/salt water (*not vinegar*) (pic) sting ray: just use hot water
3 classes of hyponatremia - mcc & Tx
always ask for *urine Na*/urine Osm i) hyp*O*volemic: appears *clinically dehyd* -Urine Na < 20 = extra-renal loss = GI (NVD), hmrg, burns, 3rd spacing -Urine Na > 20 = renal loss = diuretics, renal Dz, decr ALD 2/2 adrenal insuff -Tx: IVF ii) hyp*ER*volemic: appears *clinically overloaded* -Urine Na < 20 = extra-renal loss = nephrotic Dz (ie incr albumin), cirrhosis, CHF -Urine Na > 20 = renal loss = renal failure -Tx: IVF & *loop diuretics* iii) euvolemic: SIADH, psychogenic polydipsia, hth, beer potomania, endurance exercise -Tx: *fluid restriction* & +/- loop diuretics
Pt delivering - abrupt onset htn, hypoxic, resp fail - think? NBS?
amniotic fluid embolism NBS: Tx = supportive -Treat hypoxia (may require intubation) -Treat htn → Pressors / blood products -Avoid hypoperfusion → Place patient in LLD -Immediate delivery of fetus → Emergent c-Sx
mcc painful rectal bleeding -loc -pp -cp -Tx
anal fissure -typically located postior anal *midline*. if *off to side, think HIV, cancer, chron's* -pp: superficial tear in epidermis of anus (anoderm) -cp: chronically constipated Pt passes hard stool -Tx: *WASH* (Warm water (ie Sitz bath), Analgesia, Stool Softener, High fiber diet) + *topical NG* can help
tooth extraction earlier in the day --> now presents with intractable bleeding. NBS?
anesthetize the area w/ 1% lido w/ Epi and have Pt bite down on gauze for 10 mins
specific types of MI and their arrhythmic complications
anterior MI: Mobitz II & complete heart block (less common than inferior but in here does *NOT respond to atropine*) inferior MI: brady, 1º heart block, *mc does complete heart block but IT IS* responsive to atropine
hip dislocation a/w which nn. injuries?
anterior hip dislocation: femoral n. posterior hip dislocation: sciatic n.
toxidromes
anti-cholinergic vs sympathomimetic -AC: *HYPO*active BS; *NO* Sweating -S: *HYPER*active VS; *S*weats for *S*NS cholinergic vs opioids/sedative -C: *HYPER*active VS; *S*weats -O: *HYPO*active BS; *NO* Sweating
Hx of AAA repair --> new GI bleed - think?
aorto-enteric fistula
elderly Pt w/ mixed sx of hypo and hyper thyroidism (wt. loss, tachy) but also (decr appetite, lethargy, slow mentation) - think -Cx sign -a/w -how to best differentiate
apathetic thyrotoxicosis -sign: *unexplained tachy* -a/w CHF & AF -diff by *HR*: if tachy, think this; if brady then hth elder w/ slowed mentation & unexplained tachy = this
APGAR score
appearance, pulse, grimace, activity, respirations if G has grimace, it's 1 *not 2* G & R both have cries as +2 so *crying = good sign*
anterior shoulder dislocation clin pres
arm held in *AB*duction & *Ext Rot* *A*nterior held *A*way from body
posterior shoulder dislocation clin pres -classic XR
arm held in ADduction & Int Rot -XR: AP view shows int rot humeral head = lightbulb (pg 20)
ascending paralysis Dz descending paralysis Dz DTR maintained DTR loss
ascending: tick, GBS (tick has ataxia) descending: miller-fisher (GBS), botulism DTR maintained: MG & LEMS DTR loss: GBS, botulism, tick
preg F > 20 weeks with blunt ab trauma - monitor for how long? for what?
at least *4 hours* of fetal monitoring looking for fetal distress (ie *decelerations*) *VE*a*L*: variable, early, late *CH*o*P*: cord compression, head compression, placental insufficiency
where to apply sheet or pelvic binder in presumed pelvic fx?
at level of *greater trochanters* of femur
patchy interstitial infiltrates
atypical pneumonia - think chlamydia or mycoplasma or legio
femoral neck fx assoc with
avascular necrosis
mcc of hepatic encephalopathy -key HPI finding -Tx
azotemia (incr nitrogen in blood) 2/2 GI bleed -*sleep inversion* (sleep in day, wake at night) -Tx: lactulose, decr diet protein (less nitrogen in blood), Abx (rifaximin)
Waterhouse-Friderichsen syndrome - what is it? cp?
b/l hmrg-ic adrenal infarct a/w meningococcemia -cp: ab pain, N/V, fever, htn 2/2 meningitis
mcc malignancy in whites - main rFx; comp
basal cell carcinoma - main rFx = UV exposure; comp: low METS potential but can recur, puts you at risk for diff skin cancer BCC - think PPP *pink pearly papule* Belle of the Ball gets a Pink Present
Tx of DUB depends on?
based on amt of bleeding: -mild = iron supp; -moderate w/ *no* active bleed = iron + *progestin* (kickstarts ovulatory cycle) -moderate *W/ active bleeding: HI-dose ESTROGEN*
for GRUM/GRIMUS - which n. do you check for each fx
based on fx of bone involved - assess *OPPOSITE* N. GRI: for Galeazzi, Inf/Distal Radius so check ULNAR n. MUS: for Monteggia, Sup/Prox Ulna so check RADIAL n.
best preferred site for peripheral vein cutdown
basilic vein
why should you be weary to Dx sprains in kids
bc PEDS more likely to have injury to bone than ligament
why is Sz relative c/i to tPA
bc Todd's Paralysis: transient but focal weakness after seizure so hard to diff from stroke
why alpha blockade first theoretically
bc if you BB --> *unopposed alpha-R stim* --> HTN
why must you monitor w/ EEG a sedated/paralyzed Pt you are about to intubate -cp
bc may have *NCSE*: non-convulsive status epilepticus -Pt who had seizure now has persistent jaw/eyelid twitching
AKA: Alcoholic Keto-Acidosis -how does a normal pH manifest in a HAGMA 2/2 AKA -why would they have negative ketones? -what to do if gap is not closing -Tx
bc they have mixed A/B d/o - met acid from AG but also *vomiting* --> hypoCl, hypoK *met-alkalosis* neg ketones bc ketone usu measure acetoacetate, but major ketone you need to measure is actually *beta-hydroxybuturate* if gap not closing 2/2 adequate IVF resusc, consider *co-ingestion w/ methanol or ethylene glycol* Tx: D5NS
5 common features of tamponade
beck's triad: JVD, htn, muffled heart sounds pulses paradoxus: drop in SBP > 10 w/ *inspiration* electrical alterans
where to place padding in infants for airway
behind their torso. their larger occiput causes a passive flexion so pushing up torso
if women with suspected pelvic fx - NBS
bimanual looking for blood. if (+) speculum exam
can precipitate PTx (look on XR)
blebs
absolute c/i to therapeutic hypothermia (3)
bleeding severe sepsis pregnancy cool to 36º for 24 hrs. rewarm over 8 hours.
eyelid swelling think- mcc? Tx?
blepharitis: chronic *staph* infxn; Tx: baby shampoo, topical Abx
indications for ED thoracotomy
blunt trauma: immediate drainage of > *1.5L* from chest tube or > 200 mL/hr for 2-4 hrs penetrating trauma: arrest w/ prev witnessed cardiac activity *pre or in*-hospital
2 major finger deformities
boutonniere vs swan neck/mallet
first Sx of Cushing triad
brady think HR is always first to modify (same as in hmrg)
only absolute c/i to DPL is? disadvantage of DPL? (+) DPL constitutes?
c/i: obvious need for laporotomy disadv: miss retroperitoneal bleeds (+): 10 mL blood, presence of bile or feces
MC tarsal bone fx -cause -must r/o/assoc with -XR shows
calcaneus fracture -also axial load ie fall from height -r/o *lumbosacral fx* -XR: bohler angle < 20º
detect torsion - NBS
call urology 1st, then do doppler
15 m/o M with new onset UTI - Cx (+) and Tx'd - NBS
can f/u with PMD. do not need further testing (ie Cx, voiding cystourethrogram, renal US)
CN 6 palsy (Abducens)
can't abduct so stuck in adduction/medial deviation when fixed pic: R eye can't ABDUCT when looking to R
chronic paronychia - think? complication of felon - think?
candida osteomyelitis/tenosynovitis
itching with whitish cheese discharge - think? Tx?
candida; oral fluconazole
tinea capitis vs corporis - diff in Tx, which one contaigous?
cap: PO Rx (Griseofulvin) corp: topical clotrimazole -very contagious - spreads skin to skin
sepsis in i-c or asplenic Pt - think
capnocytophaga
How does acetazolamide work for altitude sickness?
carbonic anhydrase inh: kidney resorbs & excretes bicarb --> *acedemia* i) --> R shift = more O2 for body ii) *hyperventilation to blow off CO2 --> cerebral vasoconstriction --> decr ICP* iii) *diuretic* so less edema on board
MA Dx test for myocarditis
cardiac MRI
carotid a. relationship to tonsil
carotid is LATERAL & POSTERIOR so cut medial with sxn ready
catamenial - think?
catamenial PTx - PTx in a/w periods 2/2 ectopic endometrial tissue in thorax
sigmoid volvulus vs cecal volvulus
cecal patients much *younger (25-35 y/o* marathon runners or those w/ hx of abdominal surgeries) with otherwise identical presentation
most common abnormal CT finding in adult with head trauma
cerebral contusion
mc site of extra-pulmonary Tb?
cervical LN
myasthenia crisis suspected - NBS?
check FVC or *NIF* (NL: -80 to -100, so -20 = BAD)
Bucket handle fx in PEDS - think
child abuse
dry staccato cough w/ coryza and conjunctivitis w/ suspected PNA - think? -cp -Dx? -Tx
chlamydia PNA -atypical: *non*-prod cough w/ *lack* of fever -XR shows patchy interstitial changes ~ mycoplasma -Tx: for PNA or bacterial conjunctivitis = *2 wk oral erythromycin*
mcc of ab pain in elderly -MA Dx test? how it's done?
cholecystitis -MA: *HIDA* scan = *hi SN/SP* - aka cholescintigraphy or hepatobiliary scintigraphy is scintigraphy of the hepatobiliary tract (incl GB/bile ducts). uses iminodiacetic acid (IDA) via IV - *failure to obtain outline of GB/CBD confirms Dx* (ie *visualization of GB/CBD = (-))
scombroid vs ciguatera - which is weird neuro Sx
ciguatera bc CNS
helps prevent relapse of esophagitis
cisapride: prokinetic
if you give digibind, how long should you check dig levels for pathognomonic dysrhythmia for dig tox mc dysrhythmia a/w dig tox how many vials to give of digibind? how much does each vial bind?
ck dig for next *3 wks* patho: parosymal atrial tachycardia (ie ectopic atrial tachycardia with high degree AV block) mc = PVC vials: 5 for PEDS, 10 for unstable adults, 20 for arrest -each vial binds 0.5 mg
metacarpal neck fx - what to assess/how to ck? when to intervene?
ck for rotational deformity: ask Pt to make fist and see if fingers overlap/cross *reduce* if severe angulation: > 10º in index/middle finger > 20º in ring finger > 40º in pinky finger
good vs bad prognosis in frostbite
clear blisters: good - can be *debrided* hemorrhagic blisters: bad - *leave alone*
mcc of fulminant hepatic failure
co-infxn of hep *B&D*
CBD made up of
common hepatic duct + cystic duct
mc comp of burns in PEDS mc source of infxn in < 16 y/o
comp: infxn infxn: UTI 2/2 prolonged foley use
TOS (Thoracic Outlet) - what is it
compression of either: brachial plexus, subclavian a. or v. *b/w clavicle & 1st rib* (1st rib = thoracic outlet) think Markelle Fultz
Pt w/ massive hemothorax --> acute htn. NBS? -c/i -add to Tx
consider doing an *auto-transfusion* -c/i: sepsis, cancer, renal/liver insuff, coag Dz, *blood collecting in autotransfuser > 6 hrs* -add FFP & PLT
US neg for torsion but clinical suspicion remains - NBS?
consult OB
NBS in ICH
control ICP (Q #167)
Elbow disloc —> worry about this? NBS/
coronoid process fx of ulnar (need angio for brachial a.)
when to worry about low sodium
corrected sodium *< 120* Na *incr by 2.4mEq/L* for each 100mg GLU is over 100 (ex: GLU 400, Na 120 --> 127)
eviscerated organ in ED 2/2 stab - NBS?
cover extruded organ with *sterile gauze* & moisten liberally with *sterile saline* *NEVER* reduce - can worsen injury
meningitis a/w hi opening P -Tx -how to gauge Tx
cryptococcal meningitis -ampho B + flucytosine -serial LP's to check opening P
Cx late finding in intussusception
currant jelly stool (mix of blood & mucus)
if retrograde urethrogram normal but Pt still has gross hematuria - NBS?
cystoscopy
GSW thru extremity. if no hard or soft signs of vascular injury - NBS
d/c. no need for cTA!
number one thousand
dayam
MCC maternal death in 1st trimester vs overall
death in 1st tri: ECTOPIC death overall in preg: PE
good to decr HA *re*currence
decadron + standard abortive therapy
hyperventilation physio for ICP
decr CO2 --> *aa. v/c* --> decr cerebral blood flow/ICP
how to assess severity of Dz in RPGN
degree of crescent formation
delirium vs dementia
delirium: sleep wake cycle is disrupted & alertness impaired w/ more freq visual hallucinations both retained in dementia
hyperviscosity syndrome mgmt
depends on cause. if MM - plasmapheresis, if leukemia - leukapheresis, if PCV - phlebotomy
how to reverse coagulopathy in ICH if on anti-platelet agent?
desmopressin
found in cough syrup - think -MOA -cp -comp
dextrometorphan -NMDA-R ant (~ PCP) -cp: rotatory nystagmus, mydriasis, hyperthermia, visual hallucinations -comp: serotonin syndrome (also has serotonin reuptake inhibitor (SRI))
most SP EKG finding in pericarditis most SP finding in general for pericarditis
diffuse STE, diffuse PR depression friction rub: friction of two enflamed layers of pericardium rubbing against one another
Pt says ICD fired. you interrogate it, it did not. NBS
discharge them. it is a phantom ICD shock.
impacted food bolus passes in ER - NBS?
discharge with *outpatient endoscopy* bc impaction can be first sign of *obstructive lesion so r/o cancer*
DT clin pres? mortality rate? EtOH w/d Tx? how to decr use (2)? Abx c/i with EtOH
disorientation, hallucinations w/ unstable VS (tachy, hyperthermic); 5% -benzos -decr use: Disulfiram (antabuse); Naltrexone (blocks alcohol induced DA release) -c/i: *flagyl* with EtOH = disulfiram type rxn sweats, HA, flushing, palpitations
how does herpetic whitlow differ from paronychia & felon in terms of mgmt
do NOT drain - leads to spread of infxn
good way to measure severity of asthma Sx/response to Tx/need for ADM
do bedside spirometry/peak flow to measure FEV1
SAH: 1st Dx test
do non-con CT head: SN is almost 100% *if done w/in first 6 hrs* BUT *SN falls off if done after 12 hrs* ^also FN can be seen in severe anemia
Pt w/o active bleed has PLT 60K and INR 6 needs paracentesis - NBS
do paracentesis. PLT > 50K so it's OK. coag tests not shown to interfere or affect M/M.
ENDOCRINE
duno what # anymore 3 main endocrine organs - pancreas, thyroid, adrenals then e- & A/B
dysphagia - key hx discrepancy
dysphagia to *BOTH SOLIDS & LIQUIDS AT ONSET* of dysphagia = *motility d/o of esophagus* (ex: *esophageal spasm*) dysphagia to *SOLIDS THAT LATER PROGRESSES TO LIQUIDS = mechanical obstruction* (think *cancer*)
MCI: earliest problem vs mc problem rFx for being victim of sexual abuse 4 components of informed consent emancipated minor criteria minor can consent to what testing w/o parent approval when you think of tail coverage think
earliest: communication; mc = lack of support rFx: physically/mentally disabled, F, low SES, <25, EtOH/Rx abusers T: need to be self supporting, married (4): nature of procedure, risks, benefits, alternatives minor: marriage, military, parent or preg preg care, drug abuse/rehab, STD care tail: *occurrence based* policy > claims made policy (OBP provides coverage if event was during policy period *regardless of when it was filed*)
mc early valvular manifestation 2/2 rheumatic fever mcc of MS (mitral stenosis?)
early: MR MS: rheumatic heart Dz
normal PT but prolonged PTT (not on Heparin) - think? NBS?
either SLE/lupus anti-coagulant or a Fx def -NBS: get mixing studies
ulnar n. assoc w/ which 2 injuries
elbow dislocation (bc medial epicondyle holds ulnar n.) & galeazzi fx *GRI*-MUS: Galeazzi fx, Radial bone so think *ULNAR N.*
hepatitis admission criteria (4)
encephalopathy hypoglycemia INR > 1.5 bili > 30
fever, ab pain, uterine TTP w/ *malodorous lochia* (normal discharge from the uterus after childbirth) think -mcc -#1 rFx -Tx
endometritis -mcc: polymicrobial -rFx: *C-Sx #1*; others prolonged ROM, mult vag exams with long labor -Tx: *clinda + gent*
iatrogenic boerhaave's distinguishing fx? how to Dx?
endosopy --> rupture occurs in *PROXIMAL* esoph Dx: upper GI study w/ *water-soluble gastrograffin*
Oculocardiac reflex
entrapped EOM or eyeball compression --> brady avoid having Pt w/ entrapped mm. to perform EOM! Tx: atropine
*L*enticular hematoma with *L*ucid interval - think?
epidural hematoma
PEDS Pt with stridoe, resp distress, in tripod position having difficulty w/ secretions -Dx -Tx
epiglottitis -Dx: thumbprint sign (lat neck XR) -Tx: intubation in OR + Abx (3º cephalosporin - *rocephin* or cefotaxime)
erythema nodosum - think? cp?
erythtematous nodules (just like the name says) cp: painful red nodes on b/l ant tibia
30 y/oM HIV (+) with new onset odynophagia - think? nBS?
esophageal candidasis = AIDS defining illness NBS: start oral fluconazole
HIV Pt w/ odynophagia - think -MA Dx -Tx -rFx
esophageal candidiasis -MA Dx: needs *endoscopy* -Tx: *fluconazole for 21d* -rFx: i-c, extreme age, *recent Abx or chronic CS use*
Pt w/ hx GERD initially intolerant to solids and then later liquids - think?
esophageal stricture
long term comp of caustic injuries to GI (2)
esophageal strictures cancer
imp step in evaluating corneal abrasion
evert eye lid to r/o foreign body
Failure to... pacemaker problems (3)
failure to pace: NO pacer spikes produced (*no pacer spikes*) failure to capture: prod pacer spikes *BUT* not followed by EKG activity (just flat baseline) failure to sense: misplaced pacer spikes (spikes within QRS complex) = PACER SPIKES ON TIME BUT NO CONDUCTION (*makes no sense*)
greatest risk of CVA when you have TIA In terms of time -Tx -risk calc
first 2 days -start w/ *ASA* -ABCD2 score: age > 60, initial BP < 140/90, Clin Sx (lateral sx, speech), Duration of Sx, DM Hx
midline TTP after MVA - CT neg - still painful ROM - NBS?
flexion/extension views to r/o ligamentous injury
HSV keratitis - Dx? Tx?
fluorescein stain shows dendritic pattern/branching Tx: oral or topical acyclovir
neer classification for?
for * proximal humerus fx*: characterizes amount of displacement w/in 4 segments: anatomical/surgical neck, greater/lesser tuberosity 1 pt fx: no/min displacement 2 pt fx: displaced one fragment 3 pt fx: 2 individual fragments separate from humerus 4 pt fx: 3 fragments
Tx for priapism? which type?
for *LOW FLOW* (if you do in high flow, will enter arterial circulation and phenylephrine --> severe HTN. here just observe bc it's more tolerable) -Tx: 1) *terbutaline 0.5 mg SQ* in deltoid; 2) *aspirate 5 cc blood* from corpus cavernosum *@ 2 & 10 o clock position* 3) inject *1 cc phenylephrine 100 mcg* in same area
child w/ cough, wheezing & stridor that doesn't respond to nebs - think -which side -how to Dx
foreign body aspiration -until age of 15, either side (R & L main bronchi arise from same angle so *equal freq* b/l) -XR: *expiratory & decubitus films*: have Pt lie down on left and right. normally, the side that is down/dependent mediastinum there looks expiratory/atelectatic/small. *so if lying down on side where hemi-thorax appears inflated, that's side of FBA*
indinavir (HIV Rx) A/E? Tx?
formation of kidney stones (content is crystallized form of drug itself); Tx: stent (lithotripsy wont work)
scrotal pain out of proportion on exam - think -mcc -rFx -NBS
fournier's gangrene -mcc: polymicrobial -i-c Pt: diabetic, IVDU, EtOH -consult urology stat
scalp wound in PEDS - ensure this in tact scalp wound infxn related comp
galea aponeuortica osteomyelitis, brain abscess
mcc pancreatitis worldwide
gallstones
popliteal swelling - DDx (3)?
gastrocnemius rupture DVT Baker's Cyst
painful blisters on genitals - think? cause? Tx? -pp -cp of primary vs reactivation rash -Dx
genital herpes 2/2 HSV-2; Tx: acyclovir -pp: once infected, virus can remain *dormant and reactivate later* -cp: rash worst in 1º lasting 2 wks; reactivation lasts 1 wk -Dx: *HSV PCR* > sending viral Cx obtained after unroofing a vesicle w/ scalpel
indications for CS in PCP PNA
get *ABG*: PaO2 *< 70* or A-a gradient > 35
last line IV Rx for TOF hyper-cyanotic tet spell
get IV: 1) NS: incr preload 2) bicarb (for acidosis 2/2 LA build up from hypoperfusion) 3) invr SVR via ketamine, phenylephrine, 4) BB (decr tachy so greater diastolic filling) AVOID Epi & isoproterenol - these decr SVR! (both β1 & β2 agonists with weak alpha activity)
in DIC Pt, you give FFP but it doesn't stop the bleeding - NBS?
give *HEPARIN*: rmr MOA = activates antithrombin so incr anti-thrombin III --> inactivates thrombin --> stop cycle of unnec consumption of clotting factors DIC wastes clotting factors by consuming them without actual effect. heparin breaks the cycle so now those clotting factors can be used effectively to stop bleed
if eyelid laceration with fat protruding out - suspect
globe injury (bc eyelids dont contain subQ fat)
penetrating trauma into eye think -S/S -Cx pe -mgmt
globe rupture -S/S: subconjunctival hmrg, hyphema, teardrop pupil -pe: *Seidel sign: fluorescein waterfalls out of hole* -mgmt: *DO NOT CHECK IOP! consult ophtho* put a shield on, start IV Abx, anti-emetics
#1 rFx for PUD? for gastric or duodenal? -Tx?
h. pylori for both! -triply therapy: PPI + 2 Abx (clarithromycin + amox)
atlanto-occipital dissociation - problem?
head literally disconnected from neck
which hepatitis most related to chronic hepatitis infxn
hep C (50%) hep *C*hronic; most *a/w blood transfusions & IVDU*
AC in preg
heparin does *NOT* cross placenta so *SAFE* to use *UNLIKE WARFARIN: CROSSES PLACENTA* = goes to *WAR WITH BABY*
paint gun injxn to hand - consider this -clin pres -NBS
high P injection injury -appear benign early but rapidly lead to ischemia then *compartment syndrome* -XR, *Abx, call ortho 1st tho*
diverticulosis mgmt
high fiber diet + stool softener
suspected basilar skull Fx with neg CT - NBS? open or depressed skull Fx - NBS?
high resolution CT (thinner slices) vs MRI NSx eval & Abx
no hx heart dz, only EtOH abuse, with new onset AF - think?
holiday heart: short lived (lasting few seconds) arrhythmia that resolves w/in 24 hrs
CVA Sx based on vessel involved: ACA vs MCA
homunculus (pg 200 in book) ACA: L/E weakness (red in pic) MCA: weakness in arms & face (blue)
PEDS & botulism link
honey & canned foods are a no-no in < 12 m/o
phosphate changes and EKG
hyperP (think binds Ca so hypoCa): long QT hypoP (think excess Ca so hyperCa): shortened QT
e- abnormalities in pancreatitis (2) assoc criteria? predicts what?
hyperglycemia & *hypoCalcemia* (circulating catecholamines release calcium --> precipitation of calcium soaps in the abdominal cavity) Ranson's: predicts inpatient mortality 16, 55, 200, 250, 350 (WBC, age, GLU, AST, LDH - GAL)
blood in anterior chamber - think -mcc -Dx -Tx
hyphema -trauma, spont (if sickle cell or AC) -Dx: have *Pt sit upright, place eye shield*, r/o other injuries; measure *IOP* -Tx: topical CS + cyclopegics to decr ciliary m. spasm
hypokalemic vas thyrotoxic periodic paralysis - cp
hypoK -adolescent w/ paralysis but *w/o* HTH signs -gen TTP -*Azn M* w/ abrupt onset hypoK + paralysis 2/2 *HTH* -usu Rx induced *BOTH HAVE HYPOK!* focus on *THYROID Sx*
decr AG think hypoK + acidosis think hyperK + acidosis think
hypoalbuminemia, MM (CRAB), hyperCa/Mg, Li tox hypoK + acidosis = *diarrhea* (loss of K, think GI losses. this diarrhea, for vomit it will be hypoK with ALK) hyperK + acidosis = *ARF* (kidney cant resorb K)
most common mimic of TIA/CVA
hypoglycemia
pus in anterior chamber think - seen in?
hypopyon; in ant uveitis/iritis, corneal ulcers, endophthalmitis
(+) PPD - NBS
i) (+) PPD ii) get *CXR* ^neg: INH/vit B6 9 mos; (+) move on to ii iii) (+) CXR --> get *Sputum Cx* ^neg: INH/vit B6 9 mos; (+) 4 drug Tx (*RISE*) 6 mos.
Neonatal conjunctivitis
i) *CHEMICAL: 1-2 days* postpartum ii) *GONOCOCCAL: 3-5 days* postpartum -b/l purulent drainage (Tx: IV rocephin + topical erythromycin) iii) *CHLAMYDIA: 5-14 days* postpartum -b/l watery discharge; neonate also @ risk for *PNA* (Tx: PO & topical *erythromycin*; Tx *parents* too!) CDC warns about *CGC* (Childish Gambino's Conjunctivitis)
the psych "FAKING IT" DDx: i) Somatization ii) Hypochondriac iii) Conversion iv) Malingerer
i) *Somatization*: psych d/o --> *imagined physical Sx* (ie they imagine their 'soma' is compromised) ii) Hypo*chon*driac: *Con*vinced they are sick so pursues care - workup always neg; *no 2º gain* iii) *Conversion*: stress --> sudden neuro complaint w/o medical basis (eg son dies --> mom can't move leg; involuntary, subconscious; *converts stress to Sx*) iv) *Mal*ingerer: fake Sx but is conscious & voluntary; uncooperative w/ tests; 2º gain involved (*Mal*icious) v) Munchausen/Factitious d/o: create illness to get big work up & get hospitalized; very cooperative w/ tests *SMH* *F*kn *C*uz
2 main complications a/w HIV
i) 4x higher risk of developing DVT ii) IRIS (immune reconstitution inflm syndrome): CD4 and viral count improving but cp worsens. look for opportunistic infxn *but continue HAART*
sensitivity and specificity
i) Dz on top ii) (+) b4 (-) iii) AB CD iv) SN & SP are the vertical pillars v) PPV/NPV go horizontal
Heparin 2 types -how to monitor -reversal agent ^A/E
i) LMWH (*LO*venox/Enoxaparin) -does NOT affect PTT - measure with anti-Fx Xa assay -reverse w/ protamine suflate (1 mg for each 1 mg of Lovenox) ii) unfractionated ggt heparin -can measure w/ PTT -reverse w/ protamine suflate (1 mg for each 100U of Lovenox) ^protamine causes histamine release = *htn* so *infuse slowly*
how to deal w/ Pt. on warfarin w/ supra-therapeutic INR?
i) NO BLEED w/ INR < 5 --> hold warfarin ii) NO BLEED w/ INR 5-9 --> hold 1,2 doses of warfarin + consider PO vit K iii) NO BLEED w/ INR > 9 --> hold warfarin *+ PO vit K* iv) FATAL BLEED (reg of INR) --> *IV vit K w/ PCC*
bariatric surgeries
i) Roux-en-Y gastric bypass: Creation of small gastric pouch w/ anastomosis to jejunum (BYPASSING GASTRIC/STOMACH) ii) Gastric Banding: Placement of restrictive ring over the gastric cardia near GE jxn iii) Sleeve gastrectomy: Removes portion of greater curvature of stomach & creates sleeve out of stomach
4 elements to prove malpractice
i) a duty (to care for the Pt); ii) breach of that duty; iii) injury; iv) causation: connect the breach to the injury 3 types of breach/-feasance i) mal: performing a 'bad' action altogether (ie 1 that should not be done) 2) mis: performing the right action improperly 3) non: failure to perform that action
PLT transfusion indications (5)
i) anyone w/ PLT *< 10K* -NO ACTIVE BLEEDING BUT: ii) Pt on AC < 50K iii) invasive procedure (eg LP) or surg planned < 50K iv) ocular/neuro-surgery < 100K -w/ ACTIVE BLEEDING v) intra-op <50 K
name the personality d/o i) repeatedly threatens SI, superficial lac's on wrist ii) Trump iii) dramatic iv) disregard for and violation of the rights of others
i) borderline: emotionally labile, unstable relationships, impulsive, self destructive, threatens suicide a lot ii) narcissistic: exaggerated sense of self importance iii) histrionic: emotional, dramatic, attn-seeking, sexually seductive iv) antisocial: substance abuse, disrespects the law; think serial killer
correct sequence order of US findings on fetal US
i) gestational sac = earliest finding period ii) double decidual sign = earliest evidence of IUP (pic) iii) yolk sac = first true embryonic structure seen inside gestational sac GDY = *G*oo*DY* the baby is coming! iv) fetal pole; v) fetal heart activity (at 6 wks)
Conjunctivitis - 3 types: mcc, cp, cx pe, tx
i) viral: 2/2 adenovirus -cp: thin watery d/c *starts in 1, spreads to other* -pe: *pre-auricular LN* -Tx: warm compression ii) allergic: -cp: thin watery discharge *in both eyes @ onset* w/ itchy eyes, rhinorrhea -Tx: naphazoline (alpha 1 agonist --> v/c for red eyes) iii) Bacterial (pic) -cp: *purulent* discharge; Abx: shorten duration - not nec to treat tho
when NOT to give glucagon
if *Pheo*: glucagon incr [catecholamines] --> HTN crisis rmr: *glucagon stim test used for Dx of pheo*: give alpha blocker 1st, then glucagon --> surge in levels
3rd trimearter preg trauma Pt scans clear - NBS consider this if there is abdominal trauma
if >/= *23 wks, needs 4 hrs of fetal monitoring* ab trauma: give RhoGAM
initial regular insulin dose in DKA? when to adjust? how to know if Pt responding to Tx?
if K > 3.5, start insulin (w/ or w/o K) at *0.1 U/kg/hr* (goal is to decr GLU by 5-75 in 1st hr) keep this rate going *until GLU = 250 @ which pt you HALVE the rate to 0.05 U/kg/hr* Aim of insulin regime is to *correct the AG & acidosis*, not merely the hyperglycemia.
when to do thrombolytics for STEMI/ACS? dose?
if PCI will be delayed *>90 mins* -dose: *100 mg in 90 min* (15 in 1, 50 in 30, 35 in 60)
when can Pt with suspected iron overdose be medically cleared how to tell early on if Pt had significant exposure to iron
if by *6 hrs* no GI Sx --> can discharge so *presence of GI Sx = SIGNIFICANT EXPOSURE (ie > 40 mg/kg)*
at what age do you perform needle cric instead of surg cric?
if child *< 8*
6 w/o with laceration - Tetanus prophylaxis?
if clear/minor wound - NOTHING if dirty - just Ig
when is PEP for rabies too late
if clinical signs are seen
suspected OD with brady, htn, hyperK - avoid calcium here
if dig toxicity --> *NO Calcium* bc *STONE HEART* IV calcium c/i for Tx of *hyperK (C* BIG K DIE) if also concurrent digoxin toxicity bc: Ca may lead to an irreversible non-contractile state, due to impaired diastolic relaxation from calcium-troponin C binding rmr dig has narrow therapeutic level so OD is not much
when is gastric decontamination of actual benefit? types (4)?
if done w/in *1 hr*; 1) AC (activated charcoal) w/ cathartic (sorbitol) 2) multi-dose AC 3) WBI (whole bowel irrigation): PEG for diarrhea -gastric lavage aka stomach pumping (never rec) -syrup of ipecac (no longer c/i)
SAH: 2nd Dx test
if neg CT, *then do LP* ^if Pt has c/i or refuses, then do *CTA*
suspected DVT neg on US but D-d & suspicion high - NBS
if no c/i, daily ASA 7d and repeat US
when to do an LP on Pt with febrile seizure
if: 1) *infant* (ie < 1 y/o) + 2) *on Abx at time of Sz* ex: 6 m/o w/ fever being Tx'd w/ amox for OM p/w febrile seizure - needs LP
mc site of perforation post esophageal FB
ileocecal valve
Ileus vs. Obstruction
ileus has *HYPO*active VS SBO has *HYPER*active BS arrow w/ *air fluid levels*: in obstruction, both fluid and gas obstruct & thus collect in SI --> Cx pattern = air rises above fluid = flat surface at the "air-fluid" interface (RMR *XR only sees air so look 4 air pockets with flat bases*)
when one spine fx is detected - NBS
image ENTIRE spine
trench foot - def'n localized paresthesias that resolve w/ rewarming - think chilblain - aka? def'n?
immersion injury w/ prolonged exposure in non-freezing Tº that can cause tissue loss frostnip chilblain aka pernio; repetitive exposure to Tº above freezing point --> red/purple, painfulm inflm lesions (PICTURED)
only time to use rumack-mathew nomogram? ck level when?
in *ACUTE* ingestion *ie <24 hrs* of ingestion ck APAP level *@ 4 hrs*
cold shock: seen in? def'n? Tx?
in PEDS bc they focus on compensation for HR & SVR *but cannot modify SV* so end up feeling cold, clamped down; best Tx'd w/ IVF & *DA*
botulism vs MG
in botulism: Pt has *lack of pupillary light reflex + loss of DTR*'s (both maintained in MG)
expected UOP for hypothermic Pt
incr diuresis 2/2 cold diuresis phenomenon: systemic v/c --> incr MAP --> arteriole in glomeruli incr UOP/dump fluid to stabilize BP
sign of impending herniation most asked about herniation type - clin pres?
increased ICP so think *Cushing triad/reflex*: brady, HTN, irreg resp (down, up, irreg) *uncal*: innermost temporal lobe (uncus) compressed and pushed onto brain stem --> P on CN3 --> *i/l fixed, dilated pupil* w/ *c/l hemiplegia* UNCLE & EYE (i) ON SAME SIDE (BLOOD RELATIVE)
sentinel loop on XR
indicates *localized ileus* (abnormal peristalsis w/o evidence of mechanical obstruction) *from nearby inflm*: -in pancreatitis, seen on LUQ -in acute chole, RUQ -in appy, RLQ
criteria for BRUE
infant <1 with sudden, brief, *and now resolved event* of at least 1 of the following (*ABCT*): Altered LOC/responsiveness Breathing absent or irreg Color (cyanosis or pallor) Tone change
infectious causes a/w rhabdo (2)
influenza & legionella
invasive diarrhea def'n
infxn has invaded colonic mucosa causing: fecal WBC's blood in stool
MG common cause
infxn: choose Abx carefully as can exacerbate MG crisis
Dz that do NOT req airborne/droplet precautions
inhalational anthrax: bc no human to human trans meningococcemia
Insulinoma vs exogenous insulin
insulinoma (ie endogenous) has *high C-peptide levels* think *C*ancer w/ *C*-peptide
mcc painless rectal bleeding -2 types -cp -rFx -Tx
internal hemorrhoids -int & ext (above/below dentate line) -int: painless rectal bleed; *ext: painful thrombosis* -rFx: constipation, preg -Tx: WASH + topical CS;
main NINDS goal for acute stroke
interpret CT w/in 45 mins of arrival
mcc of intra-renal ARF? mcc of post-renal ARF?
intra: ATN post: BPH
Rx that cause black stool but FOBT (-) (2)
iron tablets pepto-bismol/maalox (Bismuth subsalicylate)
positive osmolar gap but normal AG - think -found in -metabolized to -expected Sx from toxicity -Tx
isopropyl alcohol -in *rubbing alcohol* -metabolized to acetone -Sx: *hemorrhagic gastritis*, htn, hypoglycemia -Tx: supportive; *HD* (*I*-STUMBLED)
first sign of ROSC
jump/change in end-tidal CO2 (precede carotid pulse)
only Rx that actually removes K+ from body (except dialysis)? A?E hyper K + dig - think?
kayexylate; intestinal necrosis no calcium bc --> stone heart
FP drug screen with for PCP with these Rx
ketamine & dextrometorphan
Dieulafoy's lesion - what is it? how to Dx?
large tortuous arteriole in stomach which erodes & bleeds; by endoscopy
XR showing elevation of hyoid bone above C3 -cp
laryngeal fracture -hoarse voice, stridor, subQ emphysema
tocolysis c/i (4)
let contractions keep going if: -age > 34 wks -wt < 2.5 kg grams (5.5 lbs) -cervix dilated > 4 cm -chorioamnionitis
local anesthetic toxicity Tx
lipid emulsion
how to differentiate psoriasis vs eczema
location: -Eczema/atopic dermatitis on *flexural* areas -Psoriasis on *extensor* areas (SORE elbows)
Pt alert but non-communicative. eyes are moving but quadriplegic & can't speak or swallow - think?
locked in syndrome 2/2 basilar a. infarcation
transverse myelitis -pp -mcc -cp -loc -Dx -Tx
look at demye of cord -pp: acute or subacute inflm d/o of complete transverse section of cord -mcc: viral infection (30% of cases - EBV or CMV), post-vax MS, SLE, or cancer or idiopathic -cp: ~ compressive lesion of spinal cord = focal neck/back pain, sensory loss, symmetric motor wknss -loc: usu *T-spine* -Dx: MRI (hi intensity signal on T2 weighted images); LP shows lymphocytosis & incr protein -Tx: *supportive*, consult neuro, may need CS hi dose
hocm ekg
look for *"dagger*" (septal Q) waves in *lateral* leads (think this is a big septum so should affect v4-V6 & inf leads (where LV/septum is most pronounced)
corneal ulcer - what is it? NBS? Tx?
look for corneal defect on bottom R with surrounding white hazy infiltrate NBS: *ocular emergency --> consult ophtho* (bc can lead to *blindness*); need eye Cx Tx: start on *quinolone drops*
appendicolith x ray
look for faint coin looking lesion on R iliac crest
most SN pe finding in torsion
loss of *cremasteric reflex*
earliest indicator of papilledema on fundoscopic
loss of venous pulsations
peri lunate dislocation
lunate in place but superior capitate gone (green arrow)
bilious vomiting in a neonate is this until proven otherwise - think -cp: -pp: -timeline
malrotation with volvulus -*3-7 DAY OLD* w/ new onset bilious vomiting -SI twists around SMA --> ischemia --> necrosis -usu p/w in 1st week, does *NOT* present > 1 mo
mc involved valve in IE: overall vs IVDU
mc overall: *MITRAL* (L sided so pulm septic emboli is rare whereas *CHF mc comp* 2/2 ring abscess that forms around valve) mc in IVDU: TRICUSPID (if you T*RI*/TRY drugs, hurts the *RI*GHT SIDE)
overall mc affected CN in MS mc affected CN in MS if only one nerve is affected
mc: CN2 (optic) --> optic neuritis only 1: CN6 (abducens) --> diplopia
mcc cardiac arrest in peds mc arrest rhythm amongst PEDS at what age can PEDS get surgical cric initial defib voltage dose neonatal bradycardia means what when to start CPR in infant
mcc is *resp*iratory arrest mc arrest rhythm is *aystole* surgical cric at *8* or older defib volt dose starts at *2 J/kg initially, then 4 J/kg* for all subsequent shocks neonatal brady = hypoxemia CPR in infant at *HR < 60*
mcc of otitis media mc organism of otitis media?
mcc overall: e. tube dysfxn mcc bug: strep pneumo
extra-pyramidal Sx: cause, types, Tx
mcc: hi-potency typical antipsychotic use (*haldol*) i) *D*ystonic rxn - involuntary Cx (hrs to days after Rx) ii) *A*kathisia - motor restlessness (tapping, pacing) -a/w Compazine -hrs to days iii) *P*arkinsonism - TRAPS (takes wks to mos after Rx) ^Tx *DAP* w/ the *B's*: Benadryl, Benztropine, Benzo's iv) Tardive dyskinesia - stereotyped repetitive facial movements (eg tongue protrusion, lip smacking) -a/w prolonged use; often irreversible -Tx: stop Rx
exception to rule: which open bone fx does NOT need emergent OR washout/irrigation?
metacarpal fx (unless there is gross contamination, then do need OR washout). if not too dirty, bedside irrigation + Abx + close f/u different from ALL LONG BONE Fx's
microcytic vs macrocytic anemia differential what does an elevated retic ct mean when is a coombs test used universal donor blood vs universal recipient ratio of pRBC's to other blood blood products
micro: *TAILS* = Thal, ACD, Iron, Lead, Sideroblastic macro: folate & B12 def hi retic ct (>2): means appropriate response by BM if acute destruction of RBC's; <0.5% = *aplastic crisis Coombs: r/o AIHA (detects anti-RBC Ab's) universal donor: O-; universal recipient: AB+ (they have everything, nothing is new to them) 1:1:1 of FFP:PLT:pRBC's
mc type of migraine
migraine WITHOUT aura aka common migraine migraine WITH aura aka classic migraine
Hypothermia classification & what's clinically assoc
mild: 32-35º (89.6-95) - *shivering* here, but stops < 32 moderate: 28-32º (82.4-89.6); look for *AF* severe: <28º (<82.4); unresponsiveness
NSAID induced gastric ulcer Tx
misoprostol (Synthetic prostaglandin E analogue) rmr NSAID inh PG
umbilicated lesion that can be considered an STD - think
molluscum contaigiosum
opioids & their specific A/E: morphine, fentanyl
morphine: histamine release --> htn, bronchospasm fentanyl: *chest wall rigidity* if admin *too rapidly* (Tx: naloxone, possibly RSI/intubation) ^no htn bc no histamine release since it's synthetic
bilious vomiting DDx
most dangerous as neonate = malrotation/volvulus (need emergent surg bc risk of necrosis 2/2 ischemia) most likely in 1st day = duodenal atresia (less dangerous bc surg can be delayed 24-48 hrs) if given IVF need to consider in 1st year = intussusception (esp in age 3 m/o all the way to 3 y/o)
lacunar stroke that's pure motor - located where? lacunar stroke that's pure sensory - located where?
motor: pons, internal capsule sensory: thalamus
diffuse axonal injury Cx imaging
multiple lesions at gray/white matter junction
mcc orchitis; Tx?
mumps; Tx: supp (analgesia, scrotal support, +/- Abx)
athlete with mono - think this
must avoid physical contact for *21 days* bc risk for *splenic rupture* MONO = NO MO sports
mcc of acute chest syndrome
mycoplasma pnae (or chlamydia pneumonae) atypicals
elevated trop with pericarditis - think
myocarditis
etomidate A/E
myoclonus
bugs involved in IE: native vs prosthetic vs IVDU
native valve: S. aureus (in mitral) IVDU: S. aureus (in tricuspid) prosthetic valve (first 2 mos): Staph epidermidis prosthetic valve (after 2 mos): Strep viridans
smoke inhalation injury - when to consider CN toxicity
need 2/4: -carbonaceous material in oropharynx -*neuro* Sx -*met-acid* -*LA > 8* *LMNO*: LA, Met-acid, Neuro, Oropharynx w/ carbon
in chol toxicity say atropine is given with resolution of brady & miosis (Pt now tachy with mydriasis). Pt has persistent mm. fasciculations - why? NBS?
needs 2-PAM bc atropine does NOT bind to nicotinic R and therefore can't treat NMJ issues.
ischemic CRVO complication
neovascular glaucoma
anti hypertensives if need to titrate BP
nicardipine (CCB) or labetalol (BB)
triptans A/E
non-ischemic chest pain; avoid in ACS, HTN, CVA, preg
GBS Cx Sx -key HPI detail -variant? -PE sign -Cx Dx tesgt
normally *ascending paralysis* -preceded by viral URI (flu, campylobacter) -variant/atypical *descending: Miller-Fisher* -loss of DTR's -*Albuminocytologic dissociation*: hi protein w/ NL cell counts in CSF, a hallmark finding of GBS
lunate dislocation
notice lunate kicked forward lunate = lunar = moon shaped
septic bursitis found in which 2 loc? bug?
olecranon & pre-patella; S. aureus
repetitive leaning on elbow -> golf ball elbow - think? -comp: % that are complicated, cause, Dx, Tx
olecranon bursitis -septic bursitis: in 1/3 of bursitis cases, S. aureus, aspirate and find >10K WBC, aspiration
most freq herniated organ which hemidiaphragm most affected blunt vs penetrating trauma cause which type of tears
organ: stomach diaphragm: L side (bc liver protects R) penetrating --> small tears --> take yrs to get hernia blunt --> large tears --> immediate hernia of GI to chest
O/P Tx for PNA I/P Tx for PNA
out: azithro, amox, doxy in: rocephin + doxy/azithro (azithro covers for atypicals)
eye anatomy
outer: sclera middle: choroid inner: retina
for every 10 change in pCO2, expceted pH/bicarb changes
pH changes by 0.08 (~ 0.1); HCO3 changes 1-2 (~1) for 10
first sign of flexor tenosynovitis
pain with extension (rmr its stuck in flexion so doing the opposite is what it doesn't want to do)
genital lesions: painful vs painless
painful -vesicles/blisters (herpes) -LN/buboes (LGV 2/2 chlamydia) -ulcer (chancroid 2/2 Haemophilus ducreyi) painless: -chancre (syphilis) -vesicle/ulcer (LGV 2/2 chlamydia) *but its LN not* -donovanosis also painless
HSP tetrad -Dx -Tx
palpable *P*urpura on legs *A*rthritis/arthralgias GI colicky pain (intestinal hemorrhage, intussusception) renal disease (~IgA nephropathy) HSP = *H*ematuria (2/2 nephritis). *S*kin (ie palpable purpura). *P*ain in joints/GI OR *ARENA*: Ab pain, Rash, Edema, Nephritis, Arthritis
IVF for burns
parkland formula
main salivary glands (3)
parotid (major) sublingual & submandibular
EKG match peak T short QT osborn wave u waves long QT
peak T: hyperK short QT: hyperCa, hypoP osborn wave: hypothermia U: hypoK long QT: hypoCa, hyperP
Narrowest part of the pediatric airway? in adults?
peds: cricoid cartilage (until age 5) adults: glottis
niacin deficiency (vitamin B3)
pellagra: think *4D's*: *D*ementia, *D*ermatitis (in sun exposed areas), *D*iarrhea & *D*eath
which butt abscess you can drain vs need to go to OR
peri-anal abscess ER drains: superficial IR or peri-rectal need to go to OR (bc too deep ie *above the dentate line*)
Pt in last month of preg with new onset L/E edema, DOE - think -timeline -rFx -prog
peri-partum cardiomyopathy -from last month to 5 months post-partum -advanced age, preg w/ mult fetuses, history of pre/eclampsia, cocaine use -prog: *future preg can kill mom - no more babies!*
tamponade Tx
pericardiocentesis but also *IVF (bc preload dependent)*
highest risk of teratogenicity is during
period of *organogenesis (4-12 wks)* so *1st trimester*
if Pt not tPA candidate - how to manage BP
permissive HTN OK. only intervene if *SBP > 220* or DBP > 120. reduce by *25% in 24 hrs*. use *nicardipine*.
one of few indications for tPA in DVT (not PE) (2)
phlegmasia cerulea dolens: massive ilio-femoral thrombosis --> *ischemic occlusion* (blocks collaterals) phlegmasia alba dolens: massive ilio-femoral thrombosis a/w *aa. spasm*; *NO* ischemia *bc collaterals present*
abscess above cleft in midline -differences from similar abscesses? -rFx -Tx
pilonidal cyst -these are painful, fluctuant 2/2 hair follices or gland secretions that become indurated. *perianal abscess* cause no fluctuance or pain -rFx: repetitive trauma, poor hygeine -Tx: I&D in ER; if *recurrence, send to surg*
sudden onset HA w/ visual field deficit - think? -pp -a/w -Tx
pituitary apoplexy -pit tumor --> impaired blood supply --> infarct + compression of *optic chiasm* -a/w adrenal insuff -Tx: *hydrocortisone*, surg
Pt w/ vagal nerve stimulator has Sz or feels aura - NBS -MOA
place magnet over stimulator to deliver extra stimulation -stimulates L vagus nerve to prevent Sz
painful 3rd trimester vaginal bleeding -think? -pp -rFx (5) -BI vs MA Dx -comp
placental abruption -pp: *premature separation* of NL placenta from uterine wall -rFx (5): *HTN, smoking, cocaine use*, multiparity, advanced age -BI: US; MA: cardio-tocography -future preg w/ hi risk of future abruption
for neck trauma - we're worried if this has been violated
platysma: broad sheet of muscle fibers extending from the collarbone to the angle of the jaw
boerhaave cxr features (3)
pneumo-mediastinum (arrows) also look for L pleural effusion (bc occurs L postero-lateral wall) & widened mediastinum (not seen here)
diver holds breath while ascending and severely symptomatic immediately upon ascending/surfacing. in ED, nl VS, no Sx. on pe you feel neck fullness - think which part of body mc injured in blast injury which type of blast injury occurs when person through thru air? which type of blast causes most casualties?
pneumomediastinum blast mc: TM (ear) air: 3º (Pt body flies --> blunt & penetrating trauma) casualties: 2º (objects flying thru air striking body)
hangman's vs teardrop fx in terms of location & cause
polar opposites: H: *C2* pedicle/*post*erior from hyper-*ext* (head going up like getting hung) T: *C5/C6 ant*erior from severe *flex*ion (head going down like a tear drop going down)
Bartholin cyst - mcc? Tx?
polymicrobial; I&D (Abx unnec)
mc type of ileus
post-op other causes: opioids, anti-chol (opposite of SLUDGE/diarrhea), e- (hypoK)
rare trauma injury a/w awkward falls from Sz & electrical injuries
posterior shoulder dislocation
BUN/Creatinine Ratio
pre you can absorb as much as you want lowest is intra bc cant absorb BUN post is NL HI, LO, NL
why is intubating AS Pt so scary? NBS?
pre-load dependent so take that away they may code NBS: IVF prn and have push dose pressors (phenylephrine) ready
pyogenic granuloma - a/w? -problem -prog
pregnancy -bleeds easily (collection of capillaries) -resolves spont after delivery
axillary n. assoc w/ which 2 injuries
prox humerus fx & shoulder dislocation -humeral SHAFT fx = radial n. -supracondylar fx = median n.
Ecthyma gangrenosum - a/w? -cp
pseudomonas infxn -i-c Pt w/ small area of edema --> painless nodule w/ central necrosis/hmrg
growth over cornea - think? what is it? rFx? Tx?
pterygium: triangular growth of connective tissue starting medially and extending laterally; rFx: sun/wind exposure; Tx: none
key anatomical point in inferior alveolar n. blocl
pterygomandibular raphe
eyelid lac near medial canthus - NBS
r/o lacrimal duct injury so *stain w/ fluorescein* if stain coming out of laceration = (+)
recurrent sinusitis in a PEDS Pt - think -cp
r/o nasal foreign body -cp: kid keeps sticking objects into *R nare* w/ recurrent runny nose, bloody nose & congestion
Pt with chronic indwelling foley p/w hematuria and inability to void, suprapubic pain, bladder distention - NBS?
r/o obstruction. bladder irrigation should show red tinged urine. do *CBI* (continuous bladder irrigation) via *three-way catheter*
most imp rFx in determining risk of AAA rupture at what point is elective repair of an incidentally found AAA mandated? when to do CTA vs US in suspected AAA mc misdiagnosis of AAA AAA: weakness in what layer AAA a/w
rFx: size of aneurysm repait when *> 5.5 cm* CTA if stable; US if unstable mc mis-Dx: renal colic layer: tunica media a/w: PAA (popliteal artery aneurysm)
mid-shaft humerus fracture - ck this
radial n.
based on pulse obtained, what approx SBP?
radial: SBP 80 (first to go) femoral: 70 carotid: 60
LOC in barotrauma - think
rapid ascent: air embolism rapid *de*scent: nitrogen narcosis *LOC uncommon in decompression*
MVA 3d ago. he comes & has PTx. you tx w/ chest tube. 1 hr later, acutely hypoxic again hypoxic & dyspneic think? -pp -CXR shows? -NBS
re-expansion pulmonary edema -pp: PTx that is there for at least 3d --> body starts compensating to it w/o crapping out --> large amt of air evacuated at once --> fluid fills there as a makeshift substitute -CXR: patchy infiltrate ~ PNA -NBS: NIV (BiPAP or CPAP)
gallstone ileus - what is it
recurrent cholecystitis --> adhesion of GB wall to duodenum --> *fistula formed* --> gallstones in GI --> obstruction (not technically an ileus but called one)
kehr sign
referred pain to L shoulder 2/2 splenic rupture
2 magnets seen in colon on ab XR - NBS
removal: 2 can clamp across bowel wall -- > necrosis even if you only see 1 but there's possibility of 2, still remove
modified sgarbossa
replace the *excessive discordance* rule w/ *ST/S ratio < 0.25 = (+)* basically quantifying the excessive discordance rule
new sudden onset of floaters/flashes of light w/ loss of vision - think -cp -precursor to this -Tx
retinal detachment -cp: elderly w/ severe myopia w/ sensation of *"curtain coming down"* over days to weeks -precursor to RD is *vitreous hmrg* -Tx: depends on vision: i) vision 20/40, then macula still attached & central acuity preserved, then *urgent surg w/in 24 hrs* ii) vision 20/200, then macula already deached & permanent vision loss unavoidable, then *surg in 1 wk*
blunt trauma to eye think -pe -comp -Tx ^indications (3)
retrobulbar hematoma -pe: proptosis w/ dilated non-reactive pupil -comp: acute orbital compartment syndrome -Tx: lateral canthotomy ^indications: IOP > 40, proptosis, decr visual acuity
mcc of ACQUIRED valvular dz in world
rheumatic fever
attempting VBAC (vaginal birth after C-Sx) puts you @ risk for this excessive traction on umbilical cord puts you @ risk for this
risk for uterine rupture risk for uterine inversion
Odontoid fracture -which is MC -which best/worst
rmr odontoid process = dens, bony upward projection on *C2 aka Axis* (that articulates with C1 aka Atlas) -MC: T2 (also the worst bc most unstable; see XR) -T3 is best bc best prog for healing but technically *also unstable*; T1 rare but stable
quadriceps tendon vs patellar tendon rupture
rmr your QUADS are proximal thigh mm: vastus lateralis, vastus medialis, vastus intermedius, & rectus femoris. -QTR: older Pt with XR showing *lo riding patella* -PTR: younger athlete with *hi riding patella*
best PID regiment
rocephin 250 mg IM + azithro 1 gm PO backup: rocephin 250 mg IM + doxy 100 BID 7d
retinal hemorrhage with pale centers - mcc
roth spots in IE HTN emergency w/ flamed shaped hmrg
burns rule
rule of 9 for adults: -think 9 (3) - head, arm, arm = 27 + 18 (4) - front, back, leg, leg = 72 for PEDS: -bigger head, smaller legs (*take 4.5 from each leg, add it to head*) = 2 9's, 2 14's, 3 18's = 18 + 28 + 54 = 100
missed Dx of this salter harris fx carries the worst prog -cause
salter harris 5 - prevent bone growth -direct axial compression
itching worse at night - think -cp -Cx lesion -look for
scabies -cp: eczematous type rash with overlying pustules, blisters, nodules mc in *web spaces & flexor surface of wrist*, axilla, waist, feet -Cx: *linear burrows*: linear tunnel which mite lives in -Tx: Permethrin 5% cream for all family members
anatomic snuffbox tenderness - think? -NBS - why?
scaphoid fx -splint & treat as fx *even if neg XR* bc *unique blood supply*: wraps around & goes *distal to proximal* & since most fx occur in middle third of bone, they're prone to *avascular necrosis*
MC ligamentous injury of the hand -cause -Tx -aka
scaphoid-lunate dissociation -cause: rupture of scapholunate ligament -thumb spica splint + ortho f/u -aka "Terry-Thomas sign (or David Letterman sign)" bc of gap in tooth
thich yellow crust on face/scalp -common name on scalp -Tx
seborrheic dermatitis -dandruff -ketoconazole (anti-fungal) shampoo - leave for 2 mins, use BID
posterior shoulder dislocation - think these causes
seizure or electrical injuries (ie caused by very abnormal movements)
mc A/E of MTX in ectopic mgmt - pp?
separation pain (ie abdominal pain 1 wk after Rx taken): -pp: fallopian tube distention
sepsis big 3 bugs + Abx what age is colic normal until when are b/l retinal hemorrhages normal mc reported fx in newborns
sepsis: *GEL* (GBS, E. Coli, Listeria) --> amp + gent + rocephin (if not < 1 m/o, then ceftazidine/cefotaxime) colic till 3 mos of age b/l retinal hmrg: NL during neonate (2/2 birth trauma): *abnormal in infants - consider child abuse* fx: clavicle
latent definition
serologic proof of infxn w/o sx
how to predict severity of iron tox and need for deferoxamine
serum iron > 500 serum iron > TIBC if no vomiting for 6 hrs, NOT severe
ant hip dislocation clin pres
short but also ext rot (similar to fx but less common so think fx if ext)
shoulder vs elbow dislocation - think n. involved
shoulder --> axillary n. elbow --> ulnar n. (think medial epicondyle)
alternating tachy-brady rhythm - think? causes?
sick sinus syndrome; 2/2 sarcoid, amyloid, severe CAD
Vibrio vulnificus vs Vibrio parahaemolyticus - diff/sim
similarities: both asspc w/ *raw oysters & seafood* diff: VV has *skin findings*, VP does *NOT*
meningitis PEP
single IM dose rocephin (same Rx as reg Tx) -also 2d rifampin or single PO dose cipro
pelvic fx - mcc vessel involved & timeline; capacity to hold blood?
slow venous bleeding; femur fx can hold 1.5L blood
lye aka
sodium hydroxide
spinal shock vs neurogenic shock
spinal shock: spinal cord injury (ie transection) --> reflexes lost + flaccid paralysis *BELOW* level of injury *BUT w/o circulatory collapse* neurogenic shock: CNS (brain/cord) trauma *above T6 affecting sympathetic chain ganglia and loss of SNS stim* --> v/d (*htn) + brady*
central ulceration with raised border in sun exposed area - think -T/F: dark people more at risk -imp clin sub type
squamous cell carcinoma -F: but dark skin can still get it but in *non*-sun exposed areas -*Marjolin ulcer*: SqCC 2/2 healing ulcer or burn
Pt with SCDz comes in with stroke like Sx - NBS low retic ct with SCDz - think this SCDz Pt w/ new onset ab pain? nbS?
start simple blood transfusion now and set up for exchange transfusion low retic: BM suppressed so think *aplastic crisis* a/w poss infxn (*parvovirus B19*) ab pain: consider *splenic sequestration*/auto splenectomy. need plasma exchange transfusion STAT & splenectomy eventually bc *50% recurrence* rate
mcc of pNA? person just got over viral UTI now PNA - mcc? lobar PNA in EtOH w/ currant jelly sputum - bug? loc in lungs?
strep pneumo post-viral so think S. aureus Klebsiella; *RUL* (this is where Kleb RULes)
what is a soft sign that is surprising?
subQ air, emphysema, crepitus
drowning def'n? -alternate? primary Fx in drowning survival is this predominant arrest rhythm in drowning T/F: significant e- imbalance occur in drowning
submersion into liquid with subsequent resp distress - fatal vs not fatal -alternate = *water rescue* - submersion and come back up without issue -Fx: duration of immersion -rhythm: *asystole* -F: NO e- imbalance
Acalculous cholecystitis of the mouth - think -what is it -cp
suppurative sialadenitis -basically sialadenitis (pus, fever) w/o the stone -cp: elderly, malnourished, post-op Pt
posterior fat pad in kid - think this -imp to check this -dispo
supracondylar fracture - rmr this is a UPPER ARM, not FOREARM Fx -*brachial a.* (rides anterior humerus down)/*median n.* (also rides down the middle of humerus) -admit for N/V checks
median n. assoc w/ which 2 injuries
supracondylar fx of humerus + colles/smith fx (distal radial fx)
3 big rFx on wells for DVT
surg in last 3 mos immbolization (bedridden, paralysis, plaster) cancer SIC
tarsal bones
tarsal on calcaneus *N*avicular & 3 cu*N*eiform: *M*edial (*N close to M*) 1 lateral cuboid spans all 4 medial bones
HA w/ temporal TTP - think -Dx -NBS if suspected -SN vs SP sx -comp
temporal arteritis -biopsy; ck ESR -NBS: Tx even w/o biopsy results - give CS i) if no vision loss (ie ischemic dmg): prednisone 60 mg PO and taper over 9-12 mos ii) if vision loss: solumedrol 1000 mg IV 3d -SN: new HA; SP: *jaw claudication* -comp: u/l blindness
imp PE Dx test for hip dislocation
test *dorsiflexion* for *sciatic n.*
Boyle Law relation to barotaruma
that Pressure & Volume are inversely related so in rapid ascent as you decr P (approach atmospheric P), Volume of gas increases and pushes on adjacent tissue with eventual rupture of tissue or entrance into ectopic cavities (pneumomediastinum, air embolism, etc)
THYROID STORM Tx ORDER
think *P's*: Propranolol, PTU (Propylthiouracil), Potassium iodide (KI) i) Treat Increased Adrenergic Tone -BB (*P*ropranolol): block peripheral TH fx ii) Block New Hormone Synthesis -*P*TU or MMI: blocks both TH synth + peripheral conversion from T4 to T3 (biologically active form) iii) Block New Hormone Release -*P*otassium Iodine: 1 hr after PTU - blocks both prod & release adjuncts (3): *Tylenol* (not ASA) for fever; *CS* (Hydro-cortisone 300mg IV) if assoc adrenal insuff; b-s *Abx* as this can be 2/2 non-compliance vs infxn
MCI START protocol
think ABCD's of primary survey A = no resp = BLACK = imminent death -if quick airway re-position fails --> give up, move on B = RR > 30 = *RED* C = CRF < 2 or no radial pulse = *RED* D = cant follow directions = *RED* -*start w/ RED* need immediate attn green = can walk; yellow = everyone else
4 signs of basilar skull fx
think EENT: raccoon eyes mastoid ecchymoses, hemotympanum CSF rhinorrhea
additional Rx (to PPI) in upper GI bleeds & their indications (3)
think Liver Dz/portal HTN 1) variceal bleeding: *Somatostain (octreotide)*: bc of splanchnic v/c 2) variceal bleeding: *Vasopressin*: best if profuse bleeding & endoscopy will be delayed; MOA: v/c on splanchnic arterioles w/ 2º rdxn in portal venous BP 3) cirrhosis: *Abx: IV cipro or rocephin* - i-c Pt. who needs Px against SBP/bacteremia
succinylcholine MoA
think Sux D: succinylcholine is Depolarizing
how to Tx diff AVRT
think about blocking the conduction path that is antegrade!!! If it's antegrade thru AVN, then AV nodal blocking agents make sense. What makes antidromic/WPW different is that it's antegrade thru the accessory pathway so NO AVN blocking agents bc blocking AVN will force circuit back thru Bundle of Kent! ex: AF with WPW and you use AVN blocker. Now the underlying AF has a direct unregulated path to ventricle so will conduct 1:1 from fibrillating atria to fibrillating ventricle so AF = VF. So instead need procainamide (if stable) or DCCV (if CASH)
brugada ekg
think of Brugada as a massive Hawaiian wave brugada/cowabunga triad: *RBBB (BR*ugada) + massive *"coved"* STE + TWI (in *precordial* leads) pp: sodium channelopathy --> cp: syncope w/ *FEVER*; risk of sudden death T2 more of a saddleback hump STE w/o TWI usu
ICP decreasing measures
think of the ABC's and H3 A: pre-Tx with Lidocaine B: hyperventilate C: control BP (target SBP 140-160 in ICH w/ labetalol or nifedpine) H30: *H*yperventilate (target PCO2 *30*-35), *H*OB to *30*º, *H*ypertonic saline *3.0*% or Mannitol
bones prone to avascular necrosis
think water shed supply - top down: odontoid scaphoid (mc) *femoral head*` *talus*
intubated Pt who acutely deteriorates - think
this is NOT *DOPE* -*D*isplaced ETT -*O*bstruction from secretions (ck if resistance to bagging?) -*P*Tx -*E*quipment failure
thrombosed hemorrhoids mgmt
thrombosed hemorrhoids should be incised via elliptical incision & remove clot
1st or 2nd trimester preg F w/ anxiety, palpitations, tachy, low-grade fever - think -don't confuse w/ -a/w -timeline
thyrotoxicosis of pregnancy -dont confuse w/ pre-existing HTH -a/w hyperemesis gravidarum -resolves by *20 wks so if third trimester Pt, it's not this - think PE*
GBS clinically similar to what other paralysis Dz
tick paralysis (tick has ataxia too) both are ascending paralysis with loss of DTR's
hypo or hyper pigmented circular scaly patches - think -mcc -contagious? -Tx
tinea versicolor -malassezia furfur -not contagious -Tx: selenium sulfide shampoo
SDH rFx
trauma, elederly, alcoholic, dialysis Pt
subungual hematoma Tx indications
trephination if pain AND < 48 hrs after 48 hrs, hematoma has clotted and blood won'f flow out anymore
melanoma most imp prognostic fx -criteria?
tumor thickness -ABCDE: Asymmetry, Borders irreg, Colors varying (mottled), Diameter > 6 mm, Evolving/elevated
preg mom laying supine post MVA hypotensive - NBS
turn her to the left recumbent position (ie lay her down on her *left side*) to r/o Aortocaval compression syndrome (ie IVC compressed by uterus while supine)
Wellens Syndrome -what is it -3 main points
type A: biphasic T wave (Ellen is a Bi) type B: deep symmetric TWI 1) focus V1-V3 bc *prox LAD Dz* 2) avoid stress test in them 3) need *pain free period*
10 d/o with umbilicus appearing raw and drainage w/o erythema, fever or fluctuance - think -NBS
umbilical granuloma -d/c w/ O/P f/u & silver nitrate cauterization
diff in mgmt b/w HACE & HAPE
unlike HACE, in *HAPE: immediate descent NOT 1LTx. 1lTx = O2.* 2LTx = descent, *esp if no supp O2*. also helpful: PDE-5 inh (*viagra*), not steroids or mannitol.
how to Dx volvulus/malrot
upper GI series: XR of upper GI (esophagus, stomach, duodenum) using fluoroscopy and PO barium aka esophagram aka *barium swallow*
UMN vs LMN lesion
upper: -(+) Babinski, *spasticity*, hyperreflexia LMN (anterior horn cell to distal peripheral n.): -atrophy/mm wknss, *fasciculations*, hyporeflexia
best CXR for PTx?
upright, *expiratory* film
kidney stone + infxn mgmt
ureteral stent or perQ nephrostomy tube
how to identify occult supracondylar fx
use capitellum of humerus (articulates with radial head) 1) find *anterior humeral line* 2) should *bisect middle of capitellum* (if not in capitellum midline, suspect fx) <https://www.juniorbones.com/uploads/2/5/8/8/25885124/3612278_orig.png> = notice how ant humeral line NOT bissecting capetellum = suspect fxxfxr
mcc of post partum hemorrhage -pe -Tx -2nd mcc
uterine atony -uterus will be enlarged, soft and doughy -Tx: *fundal massage, oxytocin* -2nd: retained POC in placenta - esp in *delayed* hmrg
mc pelvic tumor in women -cp -pp -Tx
uterine fibroids (leiomyoma; benign) -cp: pelvic pain w/ ab-nl vag bleed -E-R's on surface so enlarge rapidly, esp during preg and regress during menopause -Tx: start w/ hormones as above for DUB; definitive = hysterectomy
somnolent Pt w/ elevated ammonia *but normal LFT's* - think -Tx
valproic acid OD (depakote) -Tx: *L-carnitine* or HD (I-STUMBLE*D*)
neurogenic shock Tx
vasopressors: phenylephrine or DA atropine for bradycardia
CSF studies -in viral meningitis -lymphocytes -in bacterial meningitis -in fungal/TB meningitis
viral: LOW PROTEIN w/ NORMAL GLU lymphocytes seen in: viral or fungal/TB bacterial: HI PROTEIN w/ LO GLU fungal/TB: HI PROTEIN w/ LO GLU
posterior cerebral artery a/w?
vision loss (HH)
forearm deformity after cast was put on- think -pp -describe -clutch time
volkmann contracture -pp: inadequate circulation to forearm 2/2 tight case, forearm fx swelling -forearm pronated, wrist flexed, intrinsic mm. paralysis -if > 6 hours = irreversible dmg
MC inherited bleeding disorder
von Willebrand disease = vWDz
how quickly does B. cereus cause Sx
w/in 24 hrs: doesn't even last past 24 hrs so it is SERIOUS: IN & OUT
walking PNA - bug?
walking PNA aka atypical PNA mycoplasma pnae - see patchy interstitial changes other 2 are legionella and chlamydia
when to give racemic epi for croup? dispo?
when *stridor is AT REST* dispo: observe for *3 hrs*
for Methemoglobinemia, say O2-sat is 80% and you put on NC, what do you expect to happen? -NBS? -c/i in?
will stay at 80%! -needs antidote = *Methylene blue* 1-2 mg/kg slow IV -M blue c/i in *G6PD def* (@ risk populations = Afro Amr, Mediterranean descent, SE Azn's)
most SN/SP finding of SAH
xanthochromia
infected stone --> sepsis. NBS
yes they need ABx/IVF but when they ask NBS they are asking definitive Tx so needs 1/2 things: i) percutaneous nephrostomy (makeshift ureter) ii) retrograde ureteral stent
what to watch out for in Tx of kawasaki
you give ASA so make sure not some generic viral illness where you risk REYE's
rFx for recurrent febrile Sz (2) risk of febrile Sz child developing generalized epilepsy
younger age, *lower temp at time of first episode * (lower threshold to enter into Sz so may happen again) epilepsy risk: if *simple, 1% risk (double* the risk of gen pop); if *complex, 6%*
most concerning neck zone
zone 1: most to do = CTA, bronchoscopy, esophageal evaluation
flomax MOA where are R located
α-1 blocker --> stops v/c and sm. mm constriction = sm. mm. relaxation in ureter = enhances flow most R located in *distal ureter* so most benefit there
