ABEM Flash cards

Should you treat patients with lumbago with light daily activities or bed rest.

-Recommend light daily activities - not bed rest.

How are hordeolum and chalazion related, and what is the treatment?

-First comes hordeolum, then comes chalazion. -Treatment is the same for both - warm compresses.

What are the most common cause of bloody stools in pediatric patients, especially in infants?

-Rectal fissures

Vagal maneuvers may be used in a stable patient in supraventricular tachycardia. What is a preferred vagal maneuver for newborns and infants?

-Rectal stimulation

What is the length of time between the pharyngitis and renal symptoms ranges in post streptococcal glomerulonephritis?

-1 to 2 weeks

So which leg fractures in kids warrant suspicion of abuse?

-Spiral fractures of the PROXIMAL tibia and of the femur -Leg fractures in infants who aren't walking yet.

What is a catamenial pneumothorax?

-Spontaneous recurrent pneumothorax during menstruation = catamenial pneumothorax.

What is la belle indifference?

-A lack of concern by a patient about his or her situation -Can be seen with both conversion disorder and organic illness.

How do you treat pemphigus vulgaris?

-Admission, steroids and immunosuppressants.

How do you treat patient with Brigade syndrome?

-Admit the patient for cardiac monitoring and placement of an implanted defibrillator.

What is natural history of Wellens syndrome presentation?

-Anterior wall STEMI 30 to 90 days after initial presentation.

What is positive test for seroconversion from Hep B vaccination?

-Antibody level >10 mIU/mL -Repeat Hep B vaccination series if non-responder

What is Polymorphic VT?

-An unstable ventricular rhythm > 100 beats per min with frequent variations of the QRS axis, morphology, or both

Adrenergically mediated syncope suggests the presence of __________________?

-Hypertrophic cardiomyopathy. -Adrenergic situations = extreme emotions (anger, fright)

Cardiogenic shock + STEMI = _________?

-Immediate transfer for primary PCI regardless of time delay from STEMI onset.

How does congenital adrenal hyperplasia (CAH) present?

-Infants typically present between the second and fifth weeks old -Hypovolemia and hyponatremia related to the salt wasting -TX: Hydration with isotonic fluids, IV hydrocortisone

SCIWORA occurs most commonly in the ____________.

-Cervical spine.

Is smoking a risk factor for of sudden death in asthma?

-No.

What are the 2 types of high altitude sickness that kills?

-HACE -HAPE

What are chest xray findings in primary TB?

-Infiltrate in any lobe and, often, pleural effusion.

What are cxr findings in primary TB?

-Infiltrate in any lobe and, often, pleural effusion.

What the most common type of hernia?

-Inguinal: most common type of hernia

When do you consider CSF leak and a cribriform plate injury?

-Patient who got hit in the nose and has clear rhinorrhea.

Don't use procainamide and sotalol in ____________ patients.

-Patients with prolonged QT interval

Pure Muscle Weakness (Normal Sensation) know all = I'm WEAK TOO.

I = infection = Botulism, Polio, Tick paralysis M - Myasthenia graves W = WNV E = Eaton Lambert A = ALS K =K+ = potassium - Hypokalemic periodic paralysis Too= Toxin = Arsenic, lead, Ethanol, methanol, alcohol, phenothiazines, aminoglycosides

What is following periodontal ligament injury and features? Avulsion

—Completely displaced dentition out of its socket - Don't reimplant avulsed primary teeth because of the potential for injury to the developing tooth bud

Hypokalemic periodic paralysis occurs in what 2 situations?

-Inherited disorder (familial) -Thyrotoxicosis (thyrotoxic).

Wha are the 2 preferred access sites for placing a transvenous pacemaker?

-Right internal jugular vein -Left subclavian vein.

What are the hemodynamic goals in the treatment of acute aortic dissection?

-SBP 100 to 120 & heart rate < 60.

What part of clotting cascade does heparin affect? Does it cross the placenta?

-Inhibits the intrinsic limb of the clotting cascade -***Doesn't cross placenta (even LMWH doesn't)

The muscular rigidity associated with NMS is described as _________________.

"Lead pipe" in character

What are 3 causes of amnesia? = Mnemonic TTT

"Triple TTT" 1) Acute thiamine deficiency causes Wernicke's encephalopathy, which can lead to Korsakoff's psychosis (amnesia and confabulation) 2) Transient global amnesia: Inability to form new memories, lasts 6-24 hours, etiology unclear, prognosis good 3) Traumatic amnesia: Post-traumatic, anterograde or retrograde

What is the management priority to treat DIC? What are the lab findings of DIC?

#1 Treat the underlying cause (precipitating event) -If primarily bleeding manifestations, follow the prothrombin (best single test in this setting) -Give prothrombin complex concentrate -Give FFP replacement (10-15ml/kg) if the prothrombin time is prolonged + vitamin K + folate -Give platelets if needed as well If primarily thrombosis, consider low-dose heparin infusion -Labs: -Prolonged PT, aPTT (+/-) -Low platelet count -Low fibrinogen level (but may be normal yet DIC is present / In one study only 28% of DIC patients had a low fibrinogen - 22% in another study) -Elevated FDPs and d-dime

What are the 2 leading causes of pancreatitis?

#1gallstones #2ethanol abuse Other causes: -Drugs: thiazides, estrogens, salicylates, acetaminophen, antibiotics -Metabolic disorders: hyperlipidemias, hypercalcemia DKA, uremia -Viral infections: MUMPS, Coxsackie B, hepatitis, adenovirus, EBV -Bacterial infections: Salmonella, Streptococcus, Mycoplasma, Legionella

How do you diagnose Acute Rheumatic Fever?

- +strep test or rising anti streptococcal titers + 2 major criteria of JONES -Joints - Migratory arthritis -O = looks like a "heart" - Carditis -Nodules - subcut nodules -Erythema marginatum (erythema annularea b/c raised ring around lesions) -Sydehnham Chorea -Tx the arthritis associated with acute rheumatic fever with aspirin.

In children with RSV Episodes of apnea prior to evaluation or at younger than _____ month warrant admission.

- 1 Month -It is important to ask about apnea in any child who appears to have RSV. -In children with RSV. Episodes of apnea prior to evaluation or at younger than 1 month warrant admission.

What is the rule of palms for burn injuries? What is the rule of nines for adult burn injuries? What is normal urine output in burn patient?

- 1 Palm (of patient) = 1% BSA ***Know Rule of nines for adults -Rule of Nines - For adult assessment: -Head = 9 % TBSA -Each Arm = 9 % TBSA -Each leg = 18 % TBSA -Anterior trunk = 18 % TBSA -Posterior trunk = 18 % TBSA -normal U.O. >1 mL/kg/hr

What % of AMIs have normal EKG?

- 4%

What are the 5 causes of postpartum hemorrhage? T

- 5 T's: listed here by decreasing incidence -Tone (uterine atony) -Tissue (retained products of conception) -Traction (uterine inversion) -Trauma (lacerations) -Thrombosis (coagulation disorders)

Poison hemlock (Conium maculatum) =_________________________. P

- = Nicotine. -Rapid onset of GI symptoms N/V. -Tachycardia -Convulsions and respiratory failure

When is treatment indicated in children with acute OM?

- >6 months old -Severe signs or symptoms: -Moderate or severe otalgia or otalgia >48 hours or temperature >39oC.

Do you replace a G-tube that has been dislodged after 3 weeks of placement? What is treatment in this case?

- Intestinal tract has matured after 3 weeks. -Emergent replacement with another G-tube is indicated (within hours) to maintain tract potency. -Maintaining temporary patency with a Foley catheter (16F or 18F, typically) is acceptable alternative. -Confirm tube has been replaced correctly with 25 mL of a water-soluble contrast material (eg, Gastrografin) through the tube then checked with a supine abdominal radiograph.

Is normal-pressure hydrocephalus treatable?

- It is reversible -Treat with a ventriculoperitoneal shunt.

What is presentation of Waterhouse-Friderichsen syndrome?

- WF syndrome = Bilateral adrenal failure associated with meningococcemia -Presents with abdominal pain, vomiting, fever, hypotension

What is diaphoresis is strongly suggestive of?

-ACS.

What is the most common cause of a surgical abdomen?

-Appendicitis

What are the most common carriers of rabies OUTSIDE of the United States.

-Dogs

What is the most common childhood cancer?

-Leukemia

What are 2 facts about drowning statistics?

-One of top two leading causes of accidental death in children -2/3 of deaths are age < 30

How much does 1 unit PRBCs increase Hb by?

-One unit PRBCs increases Hb by 1.5 g/dL

Is magnesium treatment of choice for polymorphic VT torsades de points or monomorphic VT with a normal QT interval?

-Polymorphic VT torsades de pointes.

Individuals who have been exposed to tuberculosis require what sort of testing?

-Require immediate testing followed by repeat testing at 3 months. -If the initial test results are positive, treatment for latent TB should start immediately;

What is treatment of HAPE?

-Supplemental oxygen & If rapid reversal does not occur (failure to increase oxygen saturation to above 90% within five minutes) descent is mandatory -On board exam do rapid descent -Portable hyperbaric chamber is another option -Noninvasive ventilation may help -Nifedipine to treat pulmonary hypertension

-Posterior Cerebral Artery stroke sx's/signs:

-Supplies occipital cortex -Homonymous hemianopsia (contralateral) -Visual agnosia (can't recognize objects) -Cortical blindness (e.g. after CPR) -Minimal Motor involvement

What is treatment for erythema nodosum?

-Supportive - NSAIDs, rest, and elevation - -If you know the underlying condition, treat it, too.

What is the only treatment for fat embolism syndrome?

-Supportive care

What is the keystone of therapy for bronchiolitis?

-Supportive care with supplemental oxygen -Nasal suctioning

What are signs and symptoms of hypothyroidism?

-Weakness, lethargy -Cold intolerance -Hypothermia -Weight gain -Constipation -Generalized nonpitting edema (myxedema) -Loss of lateral third of eyebrows -CNS: slowed mentation, altered mental status, psychosis ("myxedema madness"), coma -Cardiac: CHF, bradycardia, hypotension, cardiomegaly, pericardial effusion, low voltage

Can compartment syndrome initially present with normal pulses?

-Yes! Unless there's an arterial injury, compartment syndrome initially presents with normal pulses. -Loss of pulses is uncommon in acute compartment syndrome: the pressure of the tissues does not exceed that of the arterial pressure.

In ventricular shunt headache what are the 2 things that must r/o?

-r/o infection or obstruction

What is triad symptoms of serotonin syndrome (serotonin toxicity)? What are some meds associated with serotonin syndrome?

1) AMS 2) Autonomic hyperactivity (tachycardia, HTN, diaphoresis) 3) Neuromuscular abnormalities: -Hyperreflexia -Clonus "twitchy/jerky" opposite of lead pipe rigidity -Develops over 24 hrs. -Caused by antidepressants, opioids, CNS stimulants, triptans, -Coke -Meth -Fluoxetine -Sertraline -Meperidine

What is classic triad of signs & sx's of sigmoid volvulus?

1) Abdominal pain 2) Distention 3) Constipation

What are the 3 clinical stages of pertussis?

1) Catarrhal phase 2) Paroxysmal phase 3) Convalescent phase. 1) Catarrhal phase: (Infectivity is greatest during this phase) -lasts 1 to 2 weeks -Rhinorrhea -Low-grade fever -Malaise -Conjunctival injection -Apnea occasionally -Dry cough 2) Paroxysmal stage: -Lasts 1 to 6 weeks -Staccato coughing occur 40 to 50x's/day. -Followed by a single, sudden, forceful inhalation that produces the "whoop." 3)Convalescent phase: -Lasts 2 to 3 weeks -Coughing subsides -Remains susceptible to other respiratory infections.

RUQ air on KUB = ?

1) Emphsemytous cholecystits or 2)Mesenteric ischemia

What 3 hormones does the adrenal cortex make what are their functions? What 2 hormones does the adrenal medulla make?

1) Glucocorticoids - Most important one =Cortisol- regulates metabolism of tissues and glucose 2) Mineralocorticoids - Aldosterone -regulates renal Na+ reabsorption & K+ excretion 3) Sex steroids Adrenal medulla: -Epi and norepi.

What is personality disorder of each patient below? 1) Patient is emotional, dramatic, extroverted, attention-seeking behavior. 2) Patient has exaggerated sense of abilities and achievement, self-importance. Has unrealistic ambitions

1) Histrionic Personality Disorder 2) Narcissistic Personality Disorder

What are 2 classes of diabetic oral agents?

1) Hypoglycemics (drops glc) 2) Antihyperglycemics (keeps glc from going up)

Rattlesnake envenomation is characterized what 4 criteria?

1) Local tissue damage 2) Hematologic effects (elevated prothrombin time, hypofibrinogenemia, and thrombocytopenia) 3) Neurologic effects ( muscle fasciculations) 4) Fang marks

What are the 3 stages of a Raynaud vasospasm following?cold exposure?

1) Pallor (white) from vasoconstriction 2) Cyanosis (blue) from ischemia 3) Rubor (red) from hyperemia and reperfusion.

What are 2 clues that favor a cerebellar stroke over peripheral vertigo?

1) Presence of stroke risk factors 2) Severe, unrelenting ataxia.

What types of priapism are there?

1)- Low-flow (ischemic) state (most common) characterized by slowed venous outflow -Sickle cell or other hematologic diseases -Intracavernosal injections -Drugs (phenothiazines, SSRIs, Viagra et al., neuroleptics) -Spinal cord injuries 2) High-flow (nonischemic) state from a fistula between the cavernosal artery and corpus cavernous. (arterial injury) -Trauma (straddle mechanism)

What are the 2 main objectives of heat stroke treatment?

2 main objectives: 1) Immediate cooling 2) Support of organ system function

Per the CDC, after a cut or needle stick exposure what is hep c seroconversion risk?

2% -Hepatitis C -Percutaneous transmission is common -Sexual transmission is rare -Test source for anti-HCV -No effective post-exposure prophylaxis -Hep C infected patients linked to blood transfusions & IVDA. -Of those with Hep C 50% develop chronic disease cirrhosis, CA

What are the 3 forms of anthrax infection, and which one is the one acquired in bio terrorism?

3 forms: -Inhalational - the terroriist -GI -Cutaneous -Inhalation of spores, incubation 1-6 days -Fever, chills, drenching sweats, profound fatigue, minimally productive cough, nausea, vomiting, chest discomfort → sepsis and death (24 hours) Cxr: MEDIASTINAL WIDENING, paratracheal & hilar fullness, pleural effusions, infiltrates TX: Ciprofloxacin or doxycycline, penicillin, vaccine

What is Parkland formula for calculating fluid requirements in adult? In children?

4 mL/kg/%TBSA -Adult: for > 15% TBSA partial or full thickness burns: -Give Parkland formula calculated volume: -Give 1/2 of total fluid over 1st 8 hours then remaining 1/2 over next 16 hours. -Children: Use Parkland formula + normal 24 hour maintenance fluid requirement: 4 mL/kg/% TBSA of partial thickness or full thickness burns + 24-hr Maintenance fluid. -Give 1/2 of total fluid over 1st 8 hours then remaining 1/2 over next 16 hours.

You can't clear a cervical spine injury from likely fracture if a blunt trauma victim has any of the five NEXUS criteria findings. What are the 5 criteria?

5 NEXUS criteria findings: 1) Focal neurologic deficit 2) Midline spinal tenderness 3) Altered level of consciousness 4) Intoxication 5) Distracting injury.

What are the % of stone pass when size is: -5mm? >6mm? 1 cm?

5 mm pass 50% of time this is cutoff if passes >6 mm pass 10% of the time 1 cm stones do not pass

What are the 6 causes of cp on boards?

6 causes of cp in ABEM general hospital: -Aortic dissection -ACS -Pericarditis -PE -Tension ptx -Esophageal rupture

Per the CDC, What is risk of acquiring Hep B from a needle stick or cut exposure if not successfully vaccinated? What is risk if source is HBeAg-positive?

6-30% for needle stick. 25-30% if source is HBeAg-positive

What occurs at the following levels of thrombocytopenia? <50,000 = ? <30,000 = ? < 10,000 = ?

<50,000 = excessbruising with minor trauma <30,000 = spontaneous petechiae and bruising < 10,000 = spontaneous visceral hemorrhage

What is Accelerated idioventricular rhythm, and how do you treat it?

="slow Vtach" -Wide complex regular rhythm with rate 40-120 -May last few minutes -Occurs with acute MI and reperfusion -Treatment: OBSERVE! Don't do anything. Is self-terminating, NOT destabilizing -If hypotensive, consider atrial pacing

What is positive pressure reading for compartment syndrome?

> 30 mm Hg is positive finding for compartment syndrome

What is generalized anxiety disorder?

>6 months of persistent worry and excessive anxiety

A 22 week gestation pregnant patient complains of having the following sx's and signs: -Vaginal bleeding -Abdominal pain -Hypertonic uterine contraction - & Uterine tenderness What is dx? Is ultrasound helpful? What are the causes of this dx? What are the complications of this dx?

Abruptio Placentae -Separation of the placenta from the uterine wall > 20 weeks of gestation. -Clinical: -Vaginal bleeding -Abdominal pain -Hypertonic uterine contraction -Uterine tenderness -Causes: Spontaneous, abdominal trauma -Risk factors for spontaneous abruption: Hypertension, older, ↑parity, smoking, cocaine -May have bleeding, abdominal pain, contractions, uterine tenderness. -"Painful tonic uterus" ***Ultrasound is not sensitive for diagnosis Fetal monitoring for fetal distress May be misdiagnosed as preterm labor -Complications: Fetal and maternal death, DIC -May or may not be associated with painful dark red bleeding

What are the contraindications to Thrombolytic Therapy?

Absolute contraindications: -PCI immediately available -Active bleeding from any site -CVA <6 months or hemorrhagic CVA AT ANY TIME in the past -Intracranial or intraspinal surgery or trauma < 2 months -Intracranial or intraspinal neoplasm, aneurysm or AV malformation -Suspected aortic dissection

What is the most common cause of death in persons 5 to 14 years old in the United States?

According to the CDC: #1 Accidents (unintentional injuries) #2 Cancer #3 Suicide. Among boys 5 to 14 years old, WOLRDWIDE, drowning is still a leading cause of death

What is TX for acute prostatitis vs chronic prostatitis? What do you NOT do with acute prostatitis, and what is contraindicated? How would you drain bladder if patient cannot urinate in setting of acute prostatitis?

Acute: -DO NOT massage Prostate -Foley (contraindicated) Suprapubic drain PRN - choose this as answer IV Antibiotics Chronic: Long term outpatient antibiotics

Anti-TNF medications like etanercept can put patients at risk for______________.

Anti-TNF medications like etanercept - agent approved for the treatment of the autoimmune diseases ankylosing spondylitis, juvenile rheumatoid arthritis, plaque psoriasis, psoriatic arthritis, and rheumatoid arthritis (RA)can put patients at risk for sepsis, pneumonia, and even tuberculosis. Anti-TNF medications such as etanercept cause immunosuppression, which increases the risk of developing severe infections, including sepsis, pneumonia, and tuberculosis.

What is one difference in treatment of A Flutter from A fib?

Atrial flutter: synchronized cardioversion - start at 50 J A-fib: synchronized cardioversion - start at 200 J

Patient presents after trip to Connecticut with Fever, chills, fatigue, malaise Hepatosplenomegaly & jaundice. What is diagnosis and treatment?

Babesiosis -Babesia protozoa infects vertebrate animals and cause lysis of host red blood cells -Tick-borne hemolytic disease -Can also get from blood TRANSFUSIONS -Intra-erythrocyte protozoan parasite -NE USA Fever, chills, fatigue, malaise Hepatosplenomegaly, jaundice Peripheral blood smear -- parasites in RBCs TX: Quinine + clindamycin; Atovaquone plus azithromycin

What triad is associated with cardiac tamponade?

Beck's triad: -Hypotensions -Dilated neck veins -Muffled heart sounds

What is the treatment of choice for the symptoms of cocaine and methamphetamine intoxication?

Benzodiazepine.

What's the most common cause of obstruction in the CSF production and drainage pathway?

Blood from a subarachnoid hemorrhage.

What is Brudzinski's sign? What is Kerning's sign?

Brudzinski's sign: Flexion of the hips caused by passive flexion of the neck Kernig's sign: Pain in hamstrings causes inability to straighten leg when hip is flexed to 90°

What are the primary and secondary causes of nephrosis (chronic renal failure)?

Cause 1) Primary -Idiopathic involving kidneys alone -Minimal change -Focal segmental 2) Secondary -DM -Immune disease: -HSP / SLE / Hepatitis B/C -HIV -Cancer (multiple myeloma) -Drugs (gold, mercury, heroin)

What are the differences between Crohn disease and Ulcerative Colitis?

CROHN DISEASE: -Chronic inflammatory disease of the entire GI tract (MOUTH TO ANUS) - entire colonic wall -TRANSMURAL - full thickness of bowel wall is inflamed. -SKIP LESIONS -Segmental involvement is characteristic -Abdominal pain, cramps, diarrhea (sometimes bloody), fever, perianal fissures, fistulas and abscesses, rectal prolapse, toxic megacolon -Gross blood in < 50%, so not typical in Crohns -OXALATE KIDNEY STONES, Increased oxalate absorption leads to calcium ULCERATIVE COLITIS: -ONLY COLON - Chronic inflammatory disease of only colon -GI symptoms similar to Crohn's disease -ALWAYS HAS BLOODY DIARRHEA -Major finding is almost always bloody diarrhea -TOXIC MEGACOLON (>6 CM) Transverse colon, gross distention (over 6 cm) Peritonitis, systemic toxicity -Location: rectum and colon (small bowel not affected - unlike Crohn's) -MUCOSAL & SUBMUCOSAL LAYERS ONLY, NOT full thickness of bowel wall -Risk of colon cancer increased 30-fold

What is the anion gap formula and what is the normal value?

Calculation: Na+ - (Cl- + HCO3-) ≤ 12

"Can't Treat Pain with Esters."

Can't—Cocaine Treat—Tetracaine Pain—Procaine/Chloroprocaine -Esters are commonly the culprit if there is local anesthetic allergic reaction.

What are the 3 causes of urinary retention? What is tx for urinary retention? What tool do you NOT use?

Causes: 1) Mechanical Prostatic hyperplasia (most common), meatal stenosis, urethral stricture 2) Neurologic Spinal cord injury, MS, diabetes 3) Drugs are a key precipitant/exacerbating factor OTC sympathomimetics (e.g. cold remedies) TCAs, anticholinergics, antihypertensives Treatment -Coudé catheter tip goes up if BPH suspected -DO NOT attempt filiform and followers Suprapubic drainage if cannot pass catheter and no urologist available -Discharge with catheter in place

Patient has presentation of painless loss of monocular vision. What is the cause? What is dx? What are findings on external eye and retina? What is tx? What is time window to restore vision?

Central Retina Artery Occlusion -Painless loss of monocular vision -Cause: Embolism of retinal artery -May have transient ("amarosis fugax") or permanent ***Pale retina, fixed, dilated pupil + Afferent pupillary defect Retina findings: -pale retina -Cherry red macula -"Box-car" look to retinal artery, due to sluggish flow -Treatment: -Breathing CO2 to dilate retinal arteries -Massage eyes -Acetazolamide to decrease aqueous humor production, timoptic -Anterior chamber paracentesis by ophthalmologist -90 minute time window to restore vision

Ventricular Tachycardia

Classic findings: - Regular wide complex with rate > 120 (usually >150) -Stable: procainamide > amiodarone > lidocaine, -Unstable: sync cardioversion

Supraventricular Tachycardia

Classic findings: - Regular, narrow complex tachycardia - Rate 150-200 - Absent P waves or retrograde

How does Torsade de Pointes differ form regular V. Tach?

Classic findings: - Torsade de Pointes = Polymorphic V. Tach - "a twisting of the points" - Associated with increased QT interval -Regular polymorphic VT has normal QT, but torsades has prolonged QT

What is HELLP Syndrome?

Clinical variant of preeclampsia -Can present in 2nd semester or post-partum -Multigravida Dx'd by lab tests: ***-Hemolysis -Elevated Liver enzymes -Low Platelets (<100,000) Common complaint: Epigastric or right upper quadrant pain -Hemolysis: Schistocytes (fragmented red cells) on peripheral smear schistocytes = HELLP -TX: Same as preeclampsia Bedrest, delivery of fetus, -Magnesium -Control BP if DBP >105 -No diuretics or ACE inhibitors

What are the 4 areas that kidney stones get impacted, and which one is the most common area?

Common areas of impaction 1 Renal calyx 2 Ureteropelvic junction (UPJ) 3 Pelvic Brim 4 Ureterovesical junction (UVJ) - Most common

What are the TORCH infections, and what is their significance?

Congenital infections cause fetal abnormalities and rash. T = Toxoplamosis O = Other (SYPHILLIS, EBV, VZV, HBV, Parvo B19) R = Rubella C = Cytomegalovirus (most common) H = Herpes simplex

What is advantage of Continuous venovenous hemofiltration dialysis?

Continuous venovenous hemofiltration dialysis -know -Patients in shock states, ICU -Can remove large amounts of fluids/solutes

How do you dx Candidal Vaginitis? What is tx for nonpregnant adn pregnant female?

DX.: KOH wet mount: pseudohyphae, budding yeast Tx: Fluconazole 150mg po once; Multiple OTC and prescription topical agents Topical imidazoles more effective than nystatin Pregnancy: Topical imidazoles only x 7d

What is gold standard test to detect epidural abscess? What organism is involved?

Diagnosis: -Elevated ESR, CRP -X-ray usually not helpful; may show osteo -MRI gold standard -Tx delay may cause irreversible paralysis -Staph, Strep, Bacteroides

2 fast arrhythmias MAT and S. Tach that you ________ __________.

Don't Shock.

Why do you test for malignant hyperthermia in patients with h/o masseter spasm, and how do you treat it if it occurs when using succinylcholine?

Due to a pathophysiologic overlap between masseter spasm and malignant hyperthermia, all patients who develop masseter spasm should undergo future testing for susceptibility to malignant hyperthermia. -Treated with dantrolene or a nondepolarizing neuromuscular blocking agent.

What type of peptic ulcer is most common duodenal or gastric?

Duodenal > gastric

14 y/o girl after camping trip near Duke University in North Carolina presents with fever, headache, myalgia and has NO spots. Lab: moderate Leukopenia, thrombocytopenia & hyponatremia What is diagnosis and treatment?

Ehrlichiosis = spotless rocky mountain fever all same except no spots and leukopenia -Same presentation as rocky mountain spotted fever -From tick bite Two types HME: human monocytic HGE: human granulocytic Fever, headache, myalgias Maculopapular rash LEUKOPENIA, thrombocytopenia, hyponatremia, anemia,↑ LFTs Diagnosis: Clinical suspicion -Tx: Doxycycline, tetracycline, chloramphenicol Same as RMSF Complications: DIC, renal failure, coma, death

Human Parvovirus B19 is a associated with _____________.

Erythema Infectiosum (Fifth Disease)

What is associated with altered mental status, delirium, and aggressiveness and high pain tolerance?

Excited delirium syndrome, previously referred to as agitated delirium.

How is hereditary angioedema different from angioedema to ACE inhibitors?

Familial - associated with C1 esterase inhibitor deficiency C1 esterase inhibitor inhibits complement cascade Deficiency leads to increased bradykinin -Responds to fresh frozen plasma and C1 esterase inhibitor concentrate Autosomal dominant (positive family history)

What is first line treatment of ventricular fibrillation?

First-line treatments for VF: 1) Defibrillation 2) Amiodarone

What is Charcot Triad?

For ascending cholangitis: 1) Right upper quadrant abdominal pain 2) Fever 3) Jaundice

What is serum osmolality formula?

Formula to calculate serum osmolality: 2Na +Glu/18 + BUN/2.8 + EtOH/4.6 Remember 18 + 2.8 = 4.6

"GRUM" for Galeazzi and Montegia fracture.

Galeazzi = Radius fx Ulna fx=Monteggia

How do you calculate HEART score for chest pain patients, and what is low risk score?

HEART score for chest pain patients Score History Highly suspicious 2 Moderately suspicious 1 Slightly suspicious 0 ECG Significant ST depression 2 Nonspecific depolarization disturbance 1 Normal 0 Age ≥65 year 2 45-65 year 1 <45 year 0 Risk factors ≥3 risk factors or h/o atherosclerotic disease 2 1 or 2 risk factors 1 No risk factors known 0 Troponin >2x normal limit 2 1-2x normal limit 1 ≤normal limit 0 Very low risk = HEART Score of <=3 , + negative troponin x2 at times 0 and 3 hours

HSV-2 affects what part of the body?

HSV-2: Affects 2 parts next to each other. -Painful vesicles of genitalia and anus -HSV-1 can cause encephalitis -HSV-2 can cause aseptic meningitis

Patient has lesion seen on tip of nose (Hutchinson's sign) and has blurry vision. What is diagnosis?

Herpes zoster cranial nerve involvement: -HZ ophthalmicus: Opthalmic branch of CN V, lesion seen on tip of nose (Hutchinson's sign), vision- threatening. -Tx: Acyclovir and analogs, prednisone

HCG doubles in value every 2 days for what part of the pregnancy? How soon is HCG detectable if patient is pregnant? How long is HCG detectable after an abortion or after delivery?

Human Chorionic Gonadotropic Hormone (HCG) -Doubles around every 2-3 days for first 7-8 weeks -May be positive 8-9 days after ovulation when implantation occurs -Routinely positive after 1st missed period -Still detectable up to 2-3 weeks post AB or delivery

What are the most common causes of acute pericarditis?

Idiopathic cases, most are viral in etiology.

When do you consider Penile Hair Tourniquet in patient?

In DDx of persistently crying boy (2-5 y.o.)

Why is physostigmine contraindicated in TCA toxicity?

In TCA poisoning there is QRS widening. -Use of physostigmine in this setting ---> asystole.

What are the causes of increased anion gap acidosis?

Increased anion gap metabolic acidosis: "MUDPILES" -Methanol -Uremia -DKA, AKA, starvation ketosis -Phenformin or paraldehyde -Iron or INH -Lactic acidosis -Ethylene glycol -Salicylates

What are Ranson's criteria for admission for pancreatitis?

Just know Georgia Law on admission not the 48 hours criteria. Mnemonic: Georgia Law & Calvin and Hobbs GA LAW (20, 25, 35, 55, 16) & C HOBBS (8, 10, 6, 5, 4, 6) 0 hours: -Glc >200 -AST>250 -LDH >350 -Age > 55 -WBC >16K 48 hours: -Ca++ >8 -Hct drop >10 -O2 (pO2) <60 mmHg -BUN incr >5 -Base incur >4 (# of letters in Base is 4!) -Sequestration >6L fluid -1 to 3 criteria = mild pancreatitis -Mortality rate rises with> four criteria. 3 positives: severe disease = ICU admit (Poor predictive value in acute settings)

What are the 4 Kanavel signs that point to a diagnosis of flexor tenosynovitis? Is Flexor tenosynovitis a surgical emergency? What is the most common bacteria in flexor tenosynovitis?

Kanavel signs (do NOT include erythema): 1. Tenderness over the flexor tendon sheath 2. Symmetric finger swelling 3. Pain with passive extension 4. Flexed positioning of the digit to minimize pain -Yes! -Start parenteral antibiotics and call a hand surgeon. -Staphylococcus and Streptococcus. -In sexually active patients with no identifiable source of infection, treat for presumed disseminated gonorrhea, too.

What is Weil's disease?

Leptospirosis complicated by: -Jaundice (hepatitis) and renal failure ("Weil's disease") -Pulmonary hemorrhage -ARDS -Uveitis -Optic neuritis -Myocarditis -Rhabdomyolysis

A patient with ESRD presents with hypotension and SOB. What diagnosis must you r/o, and what imaging study will you do?

MUST R/O TAMPONADE in any critically ill ESRD patient So if shock in any renal dz then must echo heart.

How do you calculate osmolal gap?

Measured osmolality - Calculated osmolality = >10 = osmolal gap +Osmolal gap = Toxic alcohols: -Ethanol -Ethylene glycol -Methanol -Isopropyl alcohol -Mannitol or glycerol

What happens to most esophageal foreign bodies if they traverse the pylorus? What type of fb needs to be removed immediately?

Most foreign bodies will pass if they traverse the pylorus (exceptions: pointed, sharp, large FB need to be removed immediately)

What are the causes of Metabolic Alkalosis?

Mnemonic - ALKALI -Aldosterone - Hyperaldonsteronism -Lasix or Loop **diuretics (Lasix) or thiazide -K in alKali ingestion of food (baking soda, milk, antacids) Milk-alkali syndrome from consuming milk & baking soda. -Anticoagulant "citrate" or Lactate (used as a storage agent in blood and during continuous forms of renal replacement therapy) -From a massive transfusion of whole blood -Loss of fluids (vomiting and GI suctioning) -Increased sodium bicarb administration (trying to correct metabolic acidosis)

What history indicate the need for imaging of spine, and what is imaging modality of choice?

Mnemonic for LBP emergency history: Elderly male with fever who is skinny from losing 20 lbs and using heroin complaining of cancer and pulsatile AAA. -Fever -Weight loss -Incontinence -Elderly -IVDA -H/o cancer or aneurysm -For suspected neurosurgical emergency like cauda equina syndrome or spinal cord compression the MRI is the imaging modality of choice.

Some Nasty Killers Have Some Capsule Protection

Mnemonic for remembering the encapsulated organisms Some—Streptococcus pneumoniae Nasty—Neisseria meningitidis Killers—Klebsiella pneumoniae Have—Haemophilus influenzae Some—Salmonella typhi Capsule—Cryptococcus neoformans Protection—Pseudomonas aeruginosa

What are high-risk findings in patients with traumatic hyphema? Who gets admitted? What is tx?

Mnemonic: "8 Blind Bloody Sickles IN Vomit" -"8-ball" hyphema or > 25% of the anterior chamber -Blind = No light perception or markedly decreased visual acuity -Bloody = Bleeding diathesis -Sickle cell disease/trait -Intraocular pressure (Elevated) -Noncompliance with outpatient instructions due to age or other factors -Vomiting (Intractable increases IOP) -Many get admitted including those with"8-ball" hyphema (100%) -Treatment: bed rest, elevate head of bed, eye shield, emergent ophtho consult -If ↑ IOP, treat same as glaucoma (topical beta-blocker, alpha agonist) -No ASA or anticoagulants -Low grade bleed and reliable patient may be treated as outpatient

What is molar pregnancy AKA? What group of diseases is a molar pregnancy part of? What are the 2 types of molar pregnancy, and how are they different? What does a molar pregnancy look like when it passes out of the uterus? What is unique about exam of uterus with molar pregnancy and about the HCG levels? What is ultrasound finding?

Molar Pregnancy Gestational Trophoblastic Disease (GTD) = Abnormal proliferation of trophoblast of the placenta. -GTD Is a category of diseases. -Molar Pregnancy is one of the diseases in this group. -Molar pregnancy = same as Hydatidiform mole -Considered BENIGN but pre-malignant -Could develop into gestational trophoblastic neoplasia (GTN) which is malignant (DON'T NEED TO KNOW ABOUT GTN) -2 TYPES of Hydatidiform Mole -Complete mole or Partial mole A) Complete mole = No fetal tissue B) Partial mole = Fetal tissue present -1st and 2nd trimester bleeding, -hyperemesis gravidarum, -no fetal heart tones -Passage of "grape-like clusters" ***Uterine size > gestational age ***HCG level greater than expected Complications: Neoplasm, preeclampsia, PE -Ultrasound = "snowstorm appearance"

What is most common cause of syncope?

Most common Vasovagal

30 y/o female presents with weakness, diplopia, and ptosis. She noticed she was more weak in her shoulders and thighs especially when she walks up stairs. What is DX? How do you confirm DX? What is TX? What are the 2 causes of respiratory distress in this type of patient?

Myasthenia Gravis Auto-antibody against acetylcholine receptors Women (20-30 yrs) > men (50-60 yrs) Associated with thymoma (25% have one) Hallmark = Muscle weakness and fatigability with diplopia, ptosis (bulbar) Weakness of eyelids, extraocular muscles, face Limb weakness proximal > distal Weakness worsens with repetitive use Precipitants any stress don't memorize this part = infection, fever, stress, adverse reactions to medication Diagnosis -Tensilon (edrophonium) test: Increases ACh, by blocking breakdown of ACh by cholinesterase = increases muscle strength -EMG = rapid fatigue -Blood: Anti-acetylcholine receptor antibodies -Tensilon can cause AV block, bradycardia, cardiac arrest - give atropine first Treatment: Physostigmine or neostigmine (longer acting tensilon) (ACH inhibitors), thymectomy, prednisone, plasmapheresis Life-threatening respiratory distress may be 2 reasons: -Exacerbation / inadequate treatment (myasthenic crisis) -Over-medication (cholinergic crisis)

FOR BOARD EXAM Think ________________________ problems first then _________________ problems SECOND for dysphagia.

NEUROLOGICAL problems first then MECHANICAL problems SECOND for dysphagia

What is difference between NMS and serotonin syndrome?

NMS develops over days to weeks & has rigidity. -Serotonin syndrome develops over 24 hours and is twitchy

Do you useD50 in pediatric hypoglycemia?

NO! it is too hypertonic to be given in a peripheral vein. -For Neonate give D10W (5 mL/kg)

What is formula for pseudohyponatremia?

Na+ drops 1.6 mEq/L for every 100 mg/dL increase in glucose over 100

What are current guidelines for a puncture wound tetanus prophylaxis?

Need to write out chart.

How do you interpret nitrite and leukocyte esterase on UA test?

Nitrite test: Specific but insensitive. Based on bacterial metabolism of nitrate to nitrite, if present = UTI Leukocyte esterase: Specific but insensitive. Based on the presence of WBCs

What 2 medications may be given for severe vasoconstriction and chest pain associated with cocaine intoxication?

Nitroglycerin or phentolamine(alpha blocker) may be given for severe vasoconstriction and chest pain associated with cocaine intoxication.

Do anthrax exposed / infected patients require isolation?

No thank goodness.

Does the presence of STEMI on the ECG rule out an aortic dissection?

No! -Inferior wall STEMI occurs with 3% of dissections due to the proximal aortic injury and involvement of the coronary arteries (usually the right coronary artery). -15% of aortic dissections present with some signs of ischemia on the ECG.

Does perforated tympanic membrane resulting from barotrauma require antibiotic therapy?

No.

Is chest radiography a sensitive screening tool to r/o acute aortic dissection.

No.

Can you use tPA if a patient's blood pressure is higher than 185 systolic or 110 diastolic? When do you consider TPA for ischemic stroke? If patient has bleed while receiving TPA for stroke what is treatment?

No. Must decrease BP with either labetalol or nicardipine. -Consider tPA: -Ischemic stroke (CT without blood) -Measurable neuro deficits -Not rapidly improving (TIA?) -Symptoms onset to drug treatment < 4.5 hours -BP below 185/110 -No other contraindications (bleeding risk) -Treat tPA ICB with cyroprecipitate

What is an obturator hernia and which sex is it more common in?

Obturator (rare): through obturator foramen. More common in woman. Presents as obstruction, pain in medial thigh (obturator nerve)

What must be missing for hypocalcemia to occur? What are causes of hypocalcemia?

One of 3 things must be missing: -PTH -Vit D -Kidney problem -Hypoparathyroidism (surgical) -Renal failure -Vitamin D deficiency -Pancreatitis -Hypomagnesemia (Mg++ necessary for PTH activity) -Drugs Don't know this: Phenytoin, cimetidine, phosphates (extensive list) -DiGeorge Syndrome

What is STEMI equivalent morphology of posterior MI?

PMI: ST-depression + tall R-waves in V1-2

In patient with mastitis/breast Abscess what organism is involved? Does patient continue to do breast feeding?

Pain, erythema, fever, edema Engorged duct becomes blocked, then infected -Staphylococcal infection -Continue breast feeding -Antibiotics (dicloxacillin, cephalexin) or I&D

Answer to slide 1016

Pericardial effusion - Electrical alternates

What is a frequently recognized pathogen in myocarditis?

Parvovirus B-19 is a frequently recognized pathogen in myocarditis

What are causes, sx's, and treatment for hypophosphatemia?

Phosphate is involved in the function of all hematologic cell lines (i.e., RBC, WBC, platelets) Causes -↑ PTH, malignancies with ↑ CA++ -Hyperventilation (respiratory alkalosis) -Hyperalimentation (common) -Decreased oral intake (alcoholics) -DKA (12-24hrs s/p tx) -Sx's and signs (ATP = energy, so low phosphate = weakness) -Muscle WEAKNESS, RESPIRATORY DEPRESSION, altered mental status, CHF, HEMOLYTIC ANEMIA, RHABDOMYOLYSIS -TX: Oral phosphate for minor cases -IV phosphate if symptomatic

What is a hallmark finding for necrotizing enterocolitis on abdominal X-ray?

Pneumatosis intestinalis, gas within the bowel wall, is a hallmark finding for necrotizing enterocolitis.

What is the the most common opportunistic respiratory infection in patients infected with AIDS, and how do you treat it? What is difference in treatment if patient is hypoxic?

Pneumocystis jiroveci pneumonia (PJP) -The #1 AIDS-defining condition in the U.S. -Fever, dry cough, disproportionate dyspnea compared to chest x-ray findings, extreme fatigue. They look worse than cxr -CXR: bilateral infiltrates, hypoxemia -Tx: TMP/SMX, -Hypoxia =steroids x 21 days

What is the most common cause of death in pertussis?

Pneumonia

When you see polycystic Kidney Disease -think __________ & _________________. Patient with h/o polycystic kidney disease c/o acute headache with no fever. What is diagnosis?

Polycystic Kidney Disease -think: -Polycystic liver -Polycystic kidney -AND CEREBRAL ANEURYSM ----->SAH -Autosomal Dominant -Flank Pain and Hematuria -Progressive Renal Failure -Association with cerebral aneurysms and SAH

A woman who delivered the day before without complications presents with brisk vaginal bleeding. What is dx and tx? A young adult female is 35 weeks pregnant. She is involved in MVA. She is in shock, and uterus feels boggy. No FHT are detected with US. What is dx?

Postpartum Hemorrhage -Uterine atony -Most common in first 24 hrs Enlarged "doughy" uterus Risks: Prolonged or precipitous labor, multiparity, multiple gestations TX: Fundal massage, oxytocin, IV fluids -Uterine rupture Prior C-section, trauma, cocaine, high doses of oxytocin -Shock, bleeding, absent heart tones, tender boggy uterus that expands -TX: Fluid resuscitation, immediate C-section

What is definition of preeclampsia?

Preeclampsia Vasospastic disease with end organ damage -Definition (> 20 weeks gestation) -New onset hypertension -> 140/90 - PLUS - -Proteinuria (ED: dip > 1+) - OR - -End organ dysfunction -Cerebral or visual symptoms -Pulmonary edema -Transaminases ≥ twice normal -Creatinine > 1.1 mg/dl -Platelets < 100,000/microliter So New onset HTN >140/90 + either proteinuria or + End organ dysfunction (one of 5 sx's or lab abnormalities) **NOTE: Peripheral edema NO LONGER part of the definition of preeclampsia

What injury commonly occurs with primary blast injuries?

Primary blast injuries commonly cause lung injury.

What medications are used for prophylaxis and for treatment for meningococcemia?

Prophylaxis: Rifampin, Cipro Tx: PCN, chloramphenicol, isolation

What mechanism accounts for most lost of heat in accidental hypothermia?

Radiation

Answer to slide #1458

RBC casts = glomerulonephritis = Nephritic syndrome

What is definition of radiation proctopathy (radiation proctitis or proctocolitis?

Radiation proctopathy is defined as epithelial damage to the rectum due to radiation that is associated with minimal or no inflammation. The term radiation proctitis is somewhat misleading, since it inaccurately implies a chronic inflammatory condition of the rectum. However, because radiation proctitis continues to be widely used,

Why is succinylcholine contraindicated in patient with h/o recent use of meth or coke?

Recent use of amphetamines, cocaine might have a prolonged duration of neuromuscular blockade because these agents competitively inhibit plasma cholinesterase, which reduces the amount of enzyme available for succinylcholine metabolism.

How is coral snake distinguished from the king snake? How is the coral snake venom different from rattle snake venom?

Red on Black, Venom Lack... Red on Yellow, Kill a Fellow" -Venom is neurotoxic -Onset of symptoms may be delayed 10-12 hours -Minimal local complaints Paresthesias, altered mental status, cranial nerve dysfunction, respiratory failure -High risk for neuromuscular weakness and respiratory failure. Supportive care, usually -Antivenom if severe; often not available

What are the types of crystals found on joint aspiration of gout vs pseudogout?

Remember N for Gout: N for Na urate crystals N for Negative birefringent uric crystals N for Needle shaped crystals Remember P for Pseudogout: P for Pyrophoshate P for Positive refringent crystals P for Pseudogout Add a line to P and get R, R for rectangle or rhomboid shaped crystals

What is the most common acid-base abnormalities in salicylate poisoning>

Respiratory alkalosis or respiratory alkalosis plus metabolic acidosis.

What is the most common cause of death among patients with myasthenia?

Respiratory failure

Ophthalmoscopic exam in HTN emergency

Retinopathy with: -Flame shaped hemorrhages -Soft Exudates -Papilledema

What is Richter's hernia?

Richter's hernia: only a portion of the bowel herniates. Even if the hernia is incarcerated or strangulated, the bowel may not be obstructed

14 y/o girl after camping trip near Duke University in North Carolina presents with fever, headache, myalgia has rash beginning on extremities, wrists, ankles, palms and soles & spreads up trunk, but spares face Lab: moderate thrombocytopenia & hyponatremia What is diagnosis and treatment?

Rocky Mountain Spotted Fever (RMSF) -Diagnosis: Clinical (don't wait for serology tests) -Tx: Doxycycline even in kids preferred, chloramphenicol -Rickettsia rickettsii (obligate intracellular bacterium) -From infected tick bite - Spring to Fall) April-September (tick season when kids are playing outside) -Children <15 -Southeastern US, North Carolina Fever, headache, myalgias Small pink macules → petechiae, purpura (from a vasculitis) / (wrists, ankles)

What plain film X-ray finding is associated with pancreatitis? What is imaging study of choice for pancreatitis?

Routine imaging is not indicated -Sentinel loop: small bowel air over pancreas in KUB Pancreatic calcifications (chronic pancreatitis) -Contrast CT is imaging study of choice (though not routinely indicated)

What is the most common pathogen in spinal epidural abscesses?

S. aureus

What is the PECARN RULE: Findings associated with very low risk of significant traumatic brain injury in children <2 years old?

SCALPS mnemonic = -Scalp hematoma, -Caregiver concern -AMS -LOC -Palpable skull fracture -Severe mechanism of injury -Normal mental status -Normal behavior per routine caregiver -No LOC¶ (LOC <5 Secs is not considered LOC) -No severe mechanism of injuryΔ -No nonfrontal scalp hematoma -No evidence of skull fracture -Severe mechanism: -Fall >0.9 m (3 feet) -Head struck by high impact object -Motor vehicle collision with patient ejection, death of another passenger, or rollover; -Pedestrian or bicyclist without helmet struck by a motorized vehicle.

How is staphylococcal scalded skin syndrome different from Stevens Johnson Syndrome?

SSSS is a diffuse tender scarlatiniform erythematous rash. -Like SJS has skin blisters and sloughing (+Nikolsky sign), BUT mucous membranes are SPARED. -Also most often seen in infants and has a low mortality rate

If Allergic reactions occurs during blood transfusions what do you do?

SX's & signs: "erythema, hives, wheezing, hypotension -Due to plasma protein incompatibilities -Reaction severity not dose-related -Discontinuation of transfusion NOT always required

What rhythm is this, and how do you treat?

See pic. Answer next slide 1058

Patient presents with acute left flank pain and h/o kidney stones. Based on ultrasound what is dx and disposition?

See slide # 1505 for answer.

What is dx?

See slide #891.

What is diagnosis of EKG?

See slide 1017 for answer

You see this on a UA. What is diagnosis?

See slide 1459

Formula for: Sensitivity = Specificity =

Sensitivity = the true-positive rate of a test. = P/(TP + FN) Specificity = the true-negative rate of a test = TN/(TN + FP)

What are differences between the 2 categories of seizures - simple and complex?

Simple: -Generalized -6 months - 5 y/o - <15 mins - occurs 1 in 24 hours. Complex: is opposite of simple -Focal - <6 months or > 5y/o - >15 mins - > 1 episode in 24 hours.

How do you tx coral cuts?

Some may contain stinging nematocysts (fire coral) Tx: same as jellyfish Soap and water Vinegar if stinging

What is a spigelian hernia?

Spigelian: lateral edge of rectus abdominis. Difficult to diagnose (CT, ultrasound)

What is hepatorenal syndrome is highly associated with?

Spontaneous bacterial peritonitis.

At what level of platelets without active bleeding or trauma should platelets transfusion occur?

Spontaneous bleeding is more likely at levels below 10,000/mm3, and prophylactic transfusion should occur for thrombocytopenia

What is treatment of Listeria monocytogenes meningitis?

Standard empiric antibiotic therapy + high-dose ampicillin

What is test of choice for diagnosing hypertrophic cardiomyopathy and what is the treatment?

Test of choice: Doppler Echo Tx: -Avoid exertion (worsens obstruction and leads to arrhythmias) -Beta blockers, calcium channel blockers (Negative inotropes) to decrease obstruction -Never use digoxin or positive inotropes (increased obstruction) -Surgical myomectomy

What 2 signs are absent in testicular torsion but present in epiddymitis? What is position of testicle when torsed? What do you always do when you suspect testicular torsion?

Testicle is elevated; horizontal lie Cremasteric reflex usually absent Prehn's sign usually absent (relief of pain by scrotal elevation - a sign of epididymitis) CALL THE UROLOGIST STAT - then do the U/S or nuclear scan!

What is the most efficient test to rapidly make a diagnosis of TB?

The most efficient test to rapidly make a diagnosis is the interferon-gamma release assay (QuantiFERON-Gold Plus).

When does trop rise, peak, and normalize?

Think 6, 12, 10 -3-6 hours (rises) -12-24 hours (peaks) -7-10 days (normalizes) know this

What are the hazards of bicarbonate use for DKA?

Think Brain, Blood, Electrolytes. -Brain: -Paradoxical CSF acidosis -Cerebral edema in children -Blood -Decreased oxygen-hemoglobin dissociation (shifts curve to left so hgb won't release O2 as well) -Electrolytes: -Overload of sodium -Hypokalemia, hypophosphatemia

What are the risk factors for infective endocarditis (IE)?

Think: Rheumatic, Valves, & 3 P's: Prior hx, Pacemaker and procedures. -Rheumatic or congenital heart disease -Prosthetic valves -IVDA -Acquired valvular disorders (e.g. AS) -Mitral valve prolapse (small risk) -Cardiac pacemakers -Prior history of endocarditis -Recent major GI, GU, dental procedures

What causes transplant-related infection?

Time post transplant: -< 1 month, wound infections, abscesses, & catheter-related infections (Opportunistic infections are much less likely in the first month because the patient is not yet fully immunosuppressed.) -1-6 months viral infections i.e. cytomegalovirus, Epstein-Barr virus, hepatitis, herpes, and adenovirus & opportunistic infection > 6 months : community-acquired infections esp. S. pneumoniae

What are the 5 phases of Iron toxicity?

Times are after ingestion. 1) Gastrointestinal (GI) phase: < 6 hours after ingestion 2) Latent, or relative stability, phase: 6-24 hours 3) Shock and metabolic acidosis: 6 hours -3 days 4) Hepatotoxicity/hepatic necrosis: 12 hours- 4 Days 5) Bowel obstruction: 2 to 8 weeks

Patient has seizure and then when recovers from postictal state he notes he has weakness of one of his arms. CT head is negative. What is the diagnosis and treatment?

Todd's paralysis: Residual neuro deficits last up to 24 hours occurs after seizure -Focal neurologic deficits may also be present, often referred to as Todd paralysis or postictal paresis. -Classic example of postictal paresis is weakness of a hand, arm, or leg that appears following a focal motor seizure involving the one side of the body.

How do you treat infant botulism?

Treatment: 1) Supportive care 2)Monitoring respiratory status for paralysis of respiratory muscles 3) Empiric treatment with IV botulism immune globulin. -Time it takes to get results from stool sample testing is too long

Management of DKA

Triad: -IVF -Insulin -Potassium -initial hypokalemia is uncommon in DKA. If see this, then patient has extreme total body potassium depletion. -if K+< 3.3 then delay insulin administration -Start KCL if K+ 5.3 or lower and if not in renal failure. -Bicarbonate Adminisration should be given when pH<6.9. -Insulin Boluses not required. No benefit over infusion. If bonus then give 0.1 unit/kg -Adminisration of glucose may be needed if glucose <200.

What is Cushing's triad or reflex?

Triad: 1)Hypertension 2)Bradycardia 3)Respiratory depression -An ominous finding that requires urgent intervention. -Relates to brainstem compression

True or False? The heterophile-agglutination test for mononucleosis can be falsely negative in children younger than 7 years.

True.

What are the 2 types of umbilical hernias?

Umbilical 1) Congenital: usually appear in FIRST MONTH, closed by end of first year 2)Acquired: obesity, pregnancy, ascites. Incarceration and strangulation are more common

Mnemonic for acute renal failure: VOIDRIGHT

V- Vasculitis, Vascular -dissection O -obstruction I - Infection D -Drugs = ATN Most common intrinsic cause R - Renal artery stenosis - I - Interstitial nephritis G- Glomerularnephritis H- Hypovolemia -Most comm cause of pre-renal failure T- Thrombosis/ Thromoboembolism

What is the triad classic presentation of normal-pressure hydrocephalus (NPH)?

Wet, weird, & wobbly -Dementia or memory loss, at young age <60 -Urinary incontinence -Ataxia. -Urinary incontinence & Ataxia develop early in the disease course

Isolated Posterior MI ST-depression + tall R-waves in V1-2 + upright Ts

What is diagnosis of EKG?

What's the most common pathogen in prostatitis?

What's the most common pathogen in prostatitis?

How you do interpret compartment pressure readings in determining compartment syndrome?

When the delta pressure (Diastolic BP - CP) <30 mm Hg = concern for Compartment syndrome. CP is Compartment pressure. Because tissue perfusion is due to the difference between arterial blood pressure and the pressure of venous return, the closer the compartment pressure comes to the arterial blood pressure, the more likely compartment pressure is to develop.

Is paraphimosis considered an acute surgical emergency?

Yes! It can cause ischemia and gangrene.

Can D-dimer with low pretest probability (using aortic detection risk score) be used to rule out acute aortic dissection?

Yes.

Should topical antibiotics should be used after foreign body removal?

Yes.

Is obesity a risk factor for decompression sickness?

Yes. Nitrogen is lipid-soluble.

If a patient's history or examination suggests cervicitis, should you go ahead and treat it before test results come back?

Yes. Prompt treatment is essential to prevent the spread of infection to sexual partners and to prevent development of more significant infection -Give azithromycin 1 g PO for C. trachomatis and ceftriaxone 250 mg IM for N. gonorrhoeae.

Why is repair of galea aponeurosis laceration important?

https://image.slidesharecdn.com/0scalp-150618000948-lva1-app6892/95/scalp-rishi-naihs-nepal-6-638.jpg?cb=1434600384 https://image.slidesharecdn.com/0scalp-150618000948-lva1-app6892/95/scalp-rishi-naihs-nepal-5-638.jpg?cb=1434600384 -It is a fibrous tissue that acts as the fascia of the scalp and inserts into the frontalis muscle, which contributes to facial expression. -Failure to repair a galeal laceration can lead to: -Subgaleal hematoma -Poor cosmetic outcome -Loss of function of the frontalis muscle

What are the 5T's of cyanotic congenital heart disease?

https://vimeo.com/93210684 shows hand mnemonic Cyanotic—Count to "5" 1 Truncus arteriosus (One trunk) (Thumb) 2 Transposition of the Two great vessels (index and middle finger intertwined) 3 Tricuspid atresia (3 fingers - index, middle, ring) 4 Tetralogy of Fallot (4 fingers index, middle, ring, & pinky) 5 Total anomalous pulmonary venous return (the Five-letter acronym TAPVR) (All 5 fingers)

On the board exam assume any sores in GU is STI. What are the 4 STI'?

the 4 STI are: -Syphilis -Herpes -Chancroid -LGV

What is following periodontal ligament injury and features? Intrusion

—Displacement of dentition into the bony socket, possible associated bony injury to the socket -Urgent evaluation by a dentist and intraoral radiographs to assess whether the underlying permanent tooth bud is involved.

What is panic disorder?

—Episodes of sudden fear -Associated with: -Tachycardia -Diaphoresis -Chest discomfort -Sense of impending doom

What are indications for Acute Dialysis?

"AEIOU" -"A"- intractable acidosis -"E"- electrolyte disarray ( K+, Na+, Ca++); -"I" - intoxicants (methanol ethylene glycol, Li, ASA); -"O"- intractable fluid overload; -"U"- uremic symptoms (n/v, seizure, encephalopathy, pericarditis, bleeding, BUN > 100 mg/dl) Refractory volume overload Refractory hypertension Refractory hyperkalemia Refractory metabolic acidosis Severe Na+ imbalance Uremia - Encephalopathy - Pericarditis - Uncontrolled Bleeding - Persistent nausea/vomiting - BUN > 100-150 Toxins

What % of patient bitten by WNV carrying mosquito get encephalitis? Is there loss of sensory function if paralysis occurs?

"Bird-mosquito-bird" cycle / dead crows -Only 20% of infected individuals become ill -Severity of illness increase with age -Flu-like illness Encephalitis/ meningitis (<1%) Can get: -Flaccid paralysis -Sensation intact Persistent neuro deficits common -CSF: Increased protein and pleocytosis (usually lymphocytic) -Send CSF and serum for IgM antibodies to WNV TX: is supportive

What are the diagnostic criteria for STEMI?

-2 contiguous leads with ST-segment elevation of > 2 mm in leads V2-V3 or > 1 mm in all other leads.

What are causes of dysfunctional platelets (increases the bleeding time / platelet function test)?

-Aspirin (for the LIFE of the platelet) -NSAIDS (ONLY AS LONG as in the blood stream) -Ticlopidine (Ticlid) / clopidogrel -Even abs

What is the antidote used to chelate iron toxicity?

-Deferoxamine

What is the most common cause of parasite diarrheal outbreaks worldwide?

-Giardia lamblia

What is placental abruption (abruptio placentae)?

-Bleeding at the decidual-placental interface causing partial or complete placental detachment prior to delivery of the fetus. - In pregnancies > 20 weeks gestation. -Clinical findings are vaginal bleeding & abdominal pain

What are the two most definitive tests for endocarditis?

-Blood cultures -Echocardiography These are the 2 Major criteria of Duke's criteria for endocarditis.

What's the most common symptom of retained vaginal foreign body?

-Blood-stained vaginal discharge

In addition to asthma what are other causes of pneumomediastinum?

-Blunt trauma -Mechanical ventilation -Marijuana or cocaine inhalation -Forced breathing as in childbirth or severe coughing.

What is the most commonly identified precipitant of GBS (Guillain-Barre syndrome)?

-Campylobacter jejune infection is the most commonly identified precipitant of GBS. -CMV, BV, and HIV infection have also been associated with GBS

Why don't you use cryoprecipitate to treat von Willebrand disease?

-Cryoprecipitate does contain von Willebrand factor, but its use is not recommended because of viral transmission risk.

What is the most common CNS fungal infection in AIDS patients, and how do you diagnose and treat it?

-Cryptococcal meningitis -Most common CNS fungal infection in AIDS patients -Diagnosis: CSF (India ink, cryptococcal antigen) -Tx: amphotericin B

What is the most common ulnar nerve mononeuropathy, and how does it present?

-Cubital tunnel syndrome. -Paresthesias of the fifth and lateral fourth fingers. -Get weakness of the intrinsic muscles.

What toxin binds cytochromes, causes anaerobic metabolism and lactic acidosis?

-Cyanide

What is pathophysiology of cyanide toxiciy?

-Cyanide is a mitochondrial toxin. -Inhibits oxidative phosphorylation so cells cannot use oxygen

What are Sodium nitrite, sodium thiosulfate, & hydroxycobalamin used as antidote for?

-Cyanide toxicity

What is cyanosis is due to in Methemoglobinemia, and why does O2 not help this?

-Cyanosis is due to the color of methemoglobin, not deoxygenated hemoglobin, so oxygen administration does not resolve it.

Transposition of great arteries

-Cyanotic congenital cardiac disease -Decreased pulse ox

What is Tetralogy of Fallot (TOF)?

-Cyanotic congenital heart disorder that has 4 anatomic features: 1) VSD (Ventricular septal defect) 2) RVOT obstruction (Right ventricular outflow tract obstruction) 3) Overriding aorta 4) RVH (Concentric right ventricular hypertrophy)

Poisoning oleander plant (Nerium oleander) = __________________.

-Digoxie toxicity = Poisoning from cardiac glycosides -Rapid onset of GI symptoms (vomiting). -Hyperkalemia occurs due to poisoning of sodium-potassium ATPase -Dysrhythmias.

What are the 3 types of cardiomyopathy?

-Dilated cardiomyopathy -Hypertrophic cardiomyopathy -Restrictive cardiomyopathy

What are components of critical care time?

-Direct patient care -Time spent gathering history from old records and from family -Time spent documenting the patient's record -Time spent discussing the case with consultants and other physicians -Interpretation of test results

What are the 3 disorders of ascent? What are the 2 disorders of descent?

-Disorders of ascent 1) Pulmonary over pressurization syndrome 2) Air embolism - sudden 3) Decompression illness - gradual -Disorders of descent 1) Squeeze syndromes 2) Nitrogen narcosis (at depth)

20 y/o female presents with migratory arthritis in multiple joints, papular or pustular rash of hands/feet, and inflammation of the tendon sheaths. What is the diagnosis & treatment?

-Disseminated GC/GC arthritis -Ceftriaxone 1g IM or IV q 24hr

-25 y/o male with fever, tweaked knee and skin lesions that look like MRSA all his over body. What is dx?

-Disseminated Gonorrhea -Fever, polyarthritis or monoarthritis (knees; ankles, wrists) tenosynovitis (hands, wrists, ankles); often seen weeks after initial exposure -Necrotic pustules on an erythematous base; may be hemorrhagic (<20 lesions total) -Joint fluid and blood often negative for organism -Genital and pharynx cultures -Evaluate also for syphilis, Chlamydia TX: Ceftriaxone, cefotaxime, ceftizoxime

How do diverticulosis & diverticulitis differ in presentations?

-Diverticulosis = bleeding -Diverticulitis = pain

What are the organisms involved in dog, cat, and human bites?

-Dog & Cat = Pasteurella multocida -Human = Eikenella corrodens

What is another name for oculocephalic reflex? When is testing it contraindicated? What does it test for, and what does it look like when it's positive?

-Doll's eyes (oculocephalic reflex) (Old doll from 1800's when eyes painted on face and don't move) -Test in comatose patient (usually absent if patient is awake) -Contraindicated in known or suspected C-spine trauma -If brainstem is intact: Eyes move in opposite direction of head movement -If brainstem is injured: Eyes stay fixed in orbits

What is the most common cause of cyanide poisoning In industrialized countries?

-Domestic fires

What do you always check before starting insulin drip for DKA?

-Don't start insulin until after check K+

What medication is used to treat Alzheimer disease?

-Donepezil

What is treatment of choice for Rocky Mountain spotted fever in pediatric patients?

-Doxycycline, even in pediatric patients. -Don't wait for test results to come back - early diagnosis and treatment of Rocky Mountain spotted fever are required to prevent fatal outcomes.

Patient presents with fever, leukocytosis, friction rub, and had a MI 3 weeks ago. What is the diagnosis & treatment?

-Dressler's Syndrome: Late complication of AMI -Pericarditis 2-8 weeks post-MI -Fever -Leukocytosis -Friction rub -Pericardial -Pleural effusions. Treatment: NSAIDs & + steroids

What is the most common location for infection in LVAD?

-Drive line is most common -Then pump pocket.

What is location of foreign body based on following sx's? -Drooling -Hoarseness -Stridor -Wheezing

-Drooling: Esophagus -Hoarseness: Level of vocal cords or above -Stridor: Just below vocal cords -Wheezing- in bronchus

What is Pulsus paradoxus, and under what conditions do you see it?

-Drop in systolic blood pressure >10 mm Hg during normal inspiration. -Seen in tamponade, although its presence has limited specificity. -Massive PE -Hemorrhagic shock -Obstructive lung disease.

What is the second most common cause of ataxia?

-Drug ingestion, but is more likely to occur in an adolescent or adult.

How do you TX bleeding on direct anticoagulants (both direct thrombin inhibitors and Xa inhibitors)?

-Drug removal from the circulation and/or gastrointestinal tract -Pro-hemostatic therapies such as antifibrinolytic agents(tranexamic acid) and DDAVP -Prothrombin complex concentrates (PCCs) - Contains Factors 2,7,9,10

Why can asthma and COPD can both lead to spontaneous pneumomediastinum or secondary pneumomediastinum?

-Due to forceful coughing in the setting of bronchospasm

What is "a timely manner" when it comes to transferring a STEMI patient for PCI?

-Duration of the STEMI < 2 hours, PCI <60 minutes - STEMI 2 to 3 hours old, PCI < 120 minutes -STEMI > 3 hours < 12 hours, PCI within 120 minutes.

What is pathophysiology of fractured penis?

-During intercourse -Rupture of the tunica albuginea -Sometimes has urethral injury. Tx: Surgery

What are symptoms of acute radiation proctitis?

-During or within six weeks of radiation therapy: -Diarrhea -Mucus discharge -Urgency -Tenesmus -Bleeding.

What are the four required legal components of negligence?

-Duty -Breach of duty (standard of care is not met) -Injury or harm -Causation

Bloody diarrhea is ___________, and the antimicrobial treatment should be extended for _____ days.

-Dysentery -3 days.

What is the most common presenting symptom in PE?

-Dyspnea. -Present in >90% of patients with PE without infarction. -Most have exertional dyspnea

What are current recommendation regarding use of cuffed or uncuffed ETTs for pediatric intubations?

-ETTs should be cuffed for all pediatric intubations EXCEPT for those involving neonates.

What part of clotting cascade does warfarin affect? How can antibiotics affect warfarin?

-EXTRINSIC limb -Inhibits liver synthesis of vitamin K-dependent EXTRINSIC limb clotting factors (II, VII, IX, and X) -Multiple drugs (particularly oral antibiotics - inhibit gut bacteria needed for vitamin K production) can increase the effects of warfarin

What does Prothrombin time (PT) test? What prolongs PT? How sensitive of test is PT to look at liver function?

-EXTRINSIC pathway (tissue factor) and common pathway (prothrombin → thrombin → fibrinogen → fibrin) -Prolonged PT -Warfarin (Coumadin) -Liver disease (the protime is the MOST SENSITIVE test of liver function) -Vitamin K deficiency -DIC

-Type O = ? Type AB = ?

-Type O = universal donor -Type AB = universal recipient

What is the preferred vasopressor in septic shock?

-Norepinephrine. Initiate if MAP<65 despite adequate IVF given.

What is mumps is caused by, and how does it present?

-Paramyxovirus Classic presentation: -Fever -Parotitis -Delayed unilateral orchitis. In female patients,can also lead to oophoritis, or infection of the ovary.

A patient presents with unexplained burns, GI sx & pancytopenia. What is likely cause and diagnosis?

-Radiation exposure.

How do you treat community acquired MRSA?

-Resistant to beta-lactam antibiotics -Milder infections: clindamycin, doxycycline or trimethoprim/sulfamethoxazole -Serious infections: vancomycin or linezolid

What is diagnostic criteria for STEMI?

-Two contiguous leads with ST-segment elevation of > 2 mm in leads V2 and V3 -or > 1 mm in all other leads

What symptoms make a complicated perirectal abscess is more likely than a perianal abscess, and what is difference in treatment between perirectal and perianal abscesses?

-Fever -Urinary retention -Perirectal abscess goes to the OR -Perianal abscess may be done as outpatient or in ER.

What are the presenting signs and symptoms of prostatitis?

-Fever and chills -Urinary symptoms -Low back pain. -Rectal exam reveals a tender and boggy prostate.

With active TB infection, what are the symptoms?

-Fever occurs during the day, and night sweats occur late in the evening as fever abates.

What are the classic signs of Kawasaki disease, and how do you treat it?

-Fever that lasts longer than 5 days even after taking antipyretic medications, as well as 4/5 below findings: 1) Redness of the eyes (conjunctivitis) 2) Red, dry, cracked lips and a red throat, swollen tongue (injected pharynx & STRAWBERRY tongue) 3) Swollen lymph nodes in the neck 4) Rash on the midsection of the body and in the genital area 5) Red, swollen palms of the hands and soles of the feet (acute phase) &DESQUAMATION (convalescent phase) TX: Aspirin, IV immunoglobulin

What type of pediatric cancer can present with symptoms similar to other, more common pediatric viral or bacterial illnesses?

-Fever, petechiae, and organomegaly make leukemia a likely diagnosis in a child.

What are the most common cause of breast lesions in women?

-Fibrocystic changes

How is phosphorus metabolized, and what is it's relationship to calcium?

-GI tract absorption -Excreted and reabsorbed in kidneys -PTH lowers serum phosphorous by blocking renal resorption -Inverse relationship with calcium ↑Ca++ = ↓phosphate ↓Ca++ = ↑phosphate

What is the most common cause of an HIV-related ED visit?

-GI-Related Emergencies -Diarrhea and abdominal pain can be related to HIV-associated infections OR NON-HIV-associated infections and noninfectious causes (often due to HIV medications) -Oropharyngeal - Group A strep, GC, HSV, CMV, C. albicans -Intestinal - consider C. difficile, Salmonella, Shigella, Campylobacter, CMV, rotavirus, Giardia, E. histolytica -Anorectal - consider GC, Chlamydia, T. pallidum -Hepatobiliary/Pancreas - E. coli, Klebsiella, Proteus, hepatitis C, B, A, CMV, E. histolytica, microsporidia

Central Retinal venous occlusion CRVO

-GRADUAL Painless loss of vision on initial presentation but painful blind eye in later stages. -Retinal findings: -"Blood and Thunder"appearance -Retinal hemorrhages -Dilated tortuous retinal veins -Cotton-wool spots -Macular edema -Optic disc edema -No effective treatment

What is a distal radius fracture and a dislocation of the distal radioulnar joint called?

-Galeazzi fracture -Complication: ulnar nerve injury

What is a gallstone ileus?

-Gallstone ileus: rupture of stone into small bowel with obstruction at ileocecal valve -Pneumobilia from perforation: air in biliary tree

In DKA what are replacement recommendations for hypokalemia?

-K < 3.3: Hold insulin, give 40 mEq per hour until ≥ 3.3 -K ≥ 3.3 - 5.0: give 20 mEq in each liter IVF to keep K 4-5 mEq/L -K ≥ 5.0: No replacement but check Q2 hr

-Second most common AIDS manifestation -Seen in gays. -Purple, painless, non-pruritic areas, flush with skin or raised strawberry-like plaques What is diagnosis?

-Kaposi's Sarcoma

Mucocutaneous lymph node syndrome is more commonly known as ___________.

-Kawasaki disease

What is profile of SSSS and how is different from SJS? What is treatment, and what drug is contraindicated?

-Kids <2 years old, think peeling sheets of skin in kids -Fever, scarlatiniform rash followed by exfoliation +Nikolsky's sign: Skin peels off with light pressure -Tx: IV penicillinase-resistant penicillin, such as nafcillin or oxacillin. Vancomycin for CA-MRSA More favorable prognosis than TEN -Steroids are contraindicated -Like SJS has skin blisters and sloughing (+Nikolsky sign), BUT mucous membranes are SPARED. -Low mortality rate

"Red on black, venom lacks" - What snake is this?

-King Snake

At what level does the conus medullaris ends for infants and for adults?

-L2-L3 in infants -L1-L2 in adults

What is most common cause of hyperkalemia?

-Lab error: Hemolysis (most common) Other causes: -Decreased output (renal failure or low aldosterone) -Aldosterone causes sodium and water retention resulting in elevated BP and loss of K in the urine -Redistribution: -Lack of insulin -Acidosis -Digoxin toxicity tissue damage, s uccinylcholine)

What medications are 1st line treatment for decreasing HTN in stroke patient?

-Labetalol or nicardipine -Can be titrated for a slow and reliable lowering of the blood pressure and have less effect on cerebral blood vessels.

What is Preterm Labor, and what precautions do you take when you do pelvic exam? What is disposition of patient?

-Labor < 37 weeks -Sterile speculum and bimanual exam -Admit, bed rest, tocolytics (terbutaline)

How do you tx electrical injuries?

-Labs (CBC, lytes, BUN, Cr, UA, CK) -Imaging (particularly high voltage - For traumatic injuries) -ECG / monitoring -HIGH VOLTAGE: ADMIT 24-48 hours of monitoring -Household exposures: No cardiac complaints, normal ECG, no cardiac disease - safe to discharge

What type of peripheral vertigo is associated with typical acute otitis media and vertigo and hearing loss?

-Labyrinthitis - caused by an infection of the labyrinth in the inner ear. -Can be caused by measles or mumps viral infection or bacterial OM.

What are the 2 labs to help diagnoses cyanide toxicity?

-Lactic acidosis (with anion gap) & increased venous oxygen saturation.

What is first-line therapy for hypertensive encephalopathy, and how much should the MAP should be lowered by in the first hour?

-Nicardipine is considered first-line therapy for hypertensive encephalopathy. -MAP should be lowered by 20% in the first hour but by no more than 25% in the first day. -MAP = [SBP + 2(DBP)]/ 3

What are 4 concerning signs of possible breast cancer?

-Nipple retraction -Discoloration -Erythema -Skin thickening

What is the best medication for preload reduction for treating CHF?

-Nitrates -Best med -Diuretics (after afterload reduction) Nesiritide (DON'T use in the ED)

Two divers are at depth exploring a reef when one notices the other appears confused and disoriented. The confused diver is not responding to commands very well. What is diagnosis and treatment?

-Nitrogen Narcosis, at depth problem -A disorder at depth from breathing compressed air -High concentrations of nitrogen are neurotoxic -Sx's: -Euphoria -Confusion -Disorientation -Poor judgment - may result in drowning -Diminished motor control -Tx: Controlled ascent to decrease the amount of dissolved nitrogen in the brain

What is role of PPI or H2 blocker, octreotide, and vasopressin in UGIB, and when are they indicated?

-No benefit to initiating PPI or H2 blocker in the ED for decreasing mortality of patients with undifferentiated UGIB Decreases need for surgery, +/- decreases rebleed -Octreotide (Somatostatin) for esophageal varices No decrease in mortality but decreases rebleed -Vasopressin (vasconstrictor) - used in variceal hemorrhage to limit exsanguination when endoscopy unavailable or delayed Need to use nitro drip with this b/c vasoconstrictor

In lower GI bleed what are the Low Risk Criteria to Discharge Home?

-No comorbid diseases -Normal vital signs -Negative or trace positive stool guaiac -Negative GI aspirate (if done) -Normal H/H (consider pt's baseline) -Good home support -Understanding of signs & symptoms of significant bleeding -F/U arranged in 24hrs

What is role of urine alkalinization or mannitol in the treatment of rhabdomyolysis?

-No evidence that urine alkalinization or mannitol is necessary.

What is acute chest syndrome in sickle cell patients?

-New infiltrate on chest xray combined with fever, dyspnea, chest pain, cough, or wheezing. Treatment: -Hydration, -O2 -Analgesia -Antibiotics -Sometimes blood transfusion and exchange transfusion needed in more severe cases.

What is drug of choice for protecting brain in HTN?

-Nicardipine drug of choice for brain -Calcium channel blocker Easily titrated -Reduces cardiac and cerebral ischemia

What is definition of conversion reaction? What must patient complain of?

-No organic basis; symptoms MUST include neurologic complaints. -Must complain of acute neurologic deficit. -They are not faking. -Inappropriate indifference -Power of suggestion may help

What is envenomation treatment of jellyfish?

-No scrubbing; will activate nematocyst -Pick off tentacles -Vinegar may help; hot water may help -NO fresh water

Is the onset of action of intravenous corticosteroids faster than the oral route?

-No! -The onset of action of IV corticosteroids = oral route, which is 1 to 2 hours.

Does Pertussis vaccination and/or previous infection confer lifelong immunity?

-No.

What are the 4 high-risk cardiac conditions for IE?

-Prosthetic cardiac valve -History of infective endocarditis -Congenital heart disease (CHD) -Cardiac transplantation recipients with cardiac valvular disease

What is an absolute contraindication to transvenous pacing?

-Prosthetic tricuspid valve

What are lab findings in nephrotic syndrome?

-Proteinuria -Hypoalbuminemia

What do these rashes have in common? -Disseminated gonorrhea -Meningococcemia -Rocky Mountain spotted fever -Secondary syphilis -Hand/foot and mouth disease -Kawasaki disease -Erythema multiform -Toxic shock syndrome.

-Rashes with lesions on the palms or soles or both

What is the most common complication of hyphema?

-Re-bleeding on day 2-5 when clot retracts -Other complications: -Increased glaucoma risk -Adhesions -Corneal blood staining -Decreased vision

De Winter's T- Waves example 3

-Upsloping ST depression (> 1mm at J-point) in the precordial leads V2-6, plus leads I & II. -Peaked anterior T waves, with the ascending limb of the T wave commencing below the isoelectric baseline. -ST elevation in aVR > 0.5mm.

De Winter's T- Waves example 2

-Upsloping ST depression in the precordial leads (> 1mm at J-point). -Peaked anterior T waves (V2-6), with the ascending limb of the T wave commencing below the isoelectric baseline. -Subtle ST elevation in aVR > 0.5mm.

De Winter's T- Waves example 1

-Upsloping ST depression in the precordial leads (> 1mm at J-point). -Peaked anterior T waves (V2-6), with the ascending limb of the T wave commencing below the isoelectric baseline. -Subtle ST elevation in aVR > 0.5mm. -Also some high lateral involvement, with subtle ST elevation in aVL plus reciprocal change in III + aVF. = LAD occlusion occurring proximal to the 1st diagonal.

What are struvite stones are caused by?

-Urea-splitting bacteria. (Proteus, Klebsiella, Corynebacterium, Staphylococcus species, and Providencia) -Urinalysis has urinary pH >7.2 -Struvite = Magnesium stones = large stones ("staghorn calculi") formed in the renal pelvis.

Patients presenting with polymorphic VT should be urgently considered for what?

-Urgent revascularization therapy due to the high incidence of ischemia.

What is management in ED for possible testicular cancer (germ cell tumor)?

-Urgent ultrasonography -Urology referral

What should you consider in status epileptics? -What is last treatment of choice in status epilepticus?

-Vit. B6 (pyridoxine) deficiency from INH OD. -TX: ABCs, glucose, thiamine, lorazepam (Ativan) phenytoin (Dilantin), phenobarb, paraldehyde, general anesthesia is final treatment -Must monitor EEG with paralysis

What 2 meds are antidote for isoniazid toxicity?

-Vitamin B6 -Pyridoxine

In hypothermic patients do you volume resuscitate with NS or LR and why?

-Volume resuscitate with NS LR is poorly metabolized by cold liver

What is most common inherited bleeding disorder., and how do you treat it?

-Von Willebrand disease -a dysfunction of factor VIII - To treat bleeding patients with milder and more common type 1 von Willebrand disease use Desmopressin -DDAVP -In severe cases use factor VIII.

What is the most common gynecological complaint in prepubertal girls?

-Vulvovaginitis -Vaginal discharge / itching / irritation Causes: Infection, irritant or allergic contact, vaginal FB, atrophic vaginitis

What is treatment for anal fissures?

-WASH regimen: -Warm water (sitz bath) -Analgesia agents -Stool softeners -High-fiber diet.

What is the first line of treatment for anal fissure?

-Warm sitz baths to reduce anal pressure -Laxatives -High fiber diet

Patient presents with shock, petechiae, adrenal infarction. What is diagnosis?

-Waterhouse-Friderichsen syndrome.

Patient with h/o alcoholism presents with classic triad: -Ataxia -Oculomotor abnormalities (eg. Nystagmus) -AMS What is diagnosis?

-Wernicke encephalopathy -Remember ccute treatment of hypoglycemia does NOT cause Wernicke encephalopathy - Caused by thiamine (vitamin B1) deficiency.

What is difference in presentation in viral vs bacterial conjunctivitis?

-Viral conjunctivitis is most likely monocular (at least early on) with a watery discharge -Bacterial is binocular with a mucopurulent discharge.

What is herpetic whitlow caused by, and how do you treat it?

-Viral infection - herpes simplex I or II -Tx: nonsurgical, DON'T mistake this for felon or paronychia -Highly contagious, keep the area covered with a clean dressing is very important.

What is most common cause of myocarditis?

-Viral, especially coxsackie B virus

When do you suspect an ovarian torsion?

-When a patient presents with intermittent lower quadrant pain, even if ultrasound imaging demonstrates good blood flow. -If ovary larger than 5 cm on ultrasound, then higher likelihood of torsion.

What is sialolithiasis, and what gland is most commonly affected?

-When a salivary gland stone gets stuck in the salivary duct -Most commonly occurs in the submandibular gland followed by the parotid gland

When should electrocardiographic LVH should be considered?

-When sum S wave in V1 or V2 and R wave in V5 or V6 > 35 mm in a patient > 35 years.

Patient presents with asymmetric polyarthralgia that typically affects weight-bearing joints. What is the diagnosis?

-Reactive arthritis -Develops following dysentery or a chlamydial infection. -Treatment of choice: NSAID, and if a chlamydial infection preceded the arthritis, then add an antibiotic

What is presentation of Valley fever, (coccidioidomycosis) and what is profile of patient?

-Recent travel to the Southwest with associated pulmonary and systemic symptoms -Fever, cough, night sweats, headache, and shortness of breath. -Self-limited in immunocompetent patients

What is the initial management of a high-pressure wound?

-Recognition and early consultation are the cornerstones of managing a high-pressure injection injury. -Followed by pain control, splinting, elevation, intravenous antibiotics, and tetanus prophylaxis.

What is the definitive treatment for decompression sickness and arterial gas embolism, and how long after sx's start can you treat?

-Recompression -May recompress up to 14 days after symptom onset

What is profile of black widow spider?

-Red "hourglass" -Outhouses, dumps, woodpiles -IMMEDIATE pain -Aggressive -N/V, cramps -Rigid abdomen (mimics appy) -Ice, opioids -Ca gluconate +/- -Antivenom available

What is goal in treatment of HTN emergency?

-Reduce MAP 30%

If you're treating a patient who had a syncopal episode and who also has a family history of sudden death what should you do with patient?

-Refer that patient for provocative testing even if the initial ECG doesn't suggest Brugada syndrome.

Is gastric decontamination with activated charcoal contraindicated in caustic ingestions?

-Relatively contraindicated in caustic ingestions because charcoal does not bind well to most caustics and can impair visualization if endoscopy is warranted.

What are the numbers/indication for perimortem cesarean delivery?

-Remember 24 and 4 for perimortem cesarean delivery • 24 weeks' gestational age (above level of umbilicus) and • Start the procedure within 4 minutes (optimally) of arrest

How do you treat bleeding after a tracheostomy?

-Removing the tube and applying silver nitrate or pressure with moist gauze.

What is the most common misdiagnosis for AAA?

-Renal colic

What is the most common misdiagnosis in cases of abdominal aortic aneurysm? What percent of renal colic have not have hematuria? What type of stone do you avoid giving NSAIDs for renal colic?

-Renal colic Hematuria may be absent in 10-20% -Avoid NSAIDS in congenital stones, any history of renal failure, bilateral stones

What are the 4 severe complications of rhabdomyolysis?

-Renal failure -Hyperkalemia -Hypocalcemia -DIC.

What is definition of Massive Blood Transfusion, and what are 4 complications from it?

-Replacement of total blood volume within 24 hours -Result in a DILUITIONAL COAGULOPATHY since packed cells are deficient in both clotting factors and platelets -HYPOTHERMIA -MICROAGGREGATES from RBC, WBC, platelet debris cause ARDS -CITRATE TOXICITY - Result in bleeding and HYPOCALCEMIA (decreased cardiac pumping power)(QT prolongation)

What is disposition of eclampsia patient treated with IV magnesium, and why?

-Require admission to an obstetric care setting with critical care capabilities for possible seizure and magnesium complications. -Signs of magnesium toxicity: -Delayed reflexes -Flaccid paralysis -Hypotension -Respiratory compromise.

Any patient with a positive purified protein derivative test requires what?

-Requires a clinical exam and chest x-ray to rule out active disease.

What is Post-Exposure Prophylaxis (PEP) for HIV?

-Requires that at least two-three antiretroviral drugs be taken for 28 days -Start as soon after exposure as possible (within 72 hours) -Tenofovir 300mg QD -Emtricitabine 200mg QD -Raltegravir 400mg BID or Dolutegravir 50mg QD

How long does acute cerebellar ataxia take to resolve in children?

-Resolves on its own in 2 to 3 weeks.

What are side effects of fentanyl?

-Resp depression -Chest wall rigidity

What area side effects of etomidate?

-Resp depression -Myoclonus -N/V -adrenocortical suppression

What is difference between restrictive & obstructivelung disease?

-Restrictive lung disease = pulmonary fibrosis, which limits total lung volume and decreases oxygen perfusion across the alveoli. -Have gradual onset dyspnea -Obstructive lung diseases = increased airway resistance. -Dyspnea & wheezing

How do sacral fractures occur, and what are the consequences?

-Result of vertical shear or lateral compression forces and can lead to neurovascular injury. -Injury to the sacral nerve roots can lead to: -Decreased perineal sensation -Decreased anal sphincter tone -Difficulty voiding -Sexual dysfunction. -Associated with pelvic vascular trauma and hemodynamic instability.

How does Central Pontine Myelinolysis occur?

-Results from too rapid correction of hyponatremia -Occurs 24-48 hours after rapid correction -Symptoms include confusion progressing to cranial nerve deficits to quadriparesis to locked-in syndrome; -dysphagia, dysarthria, paresis

What is the most common cause of late or delayed postpartum hemorrhage?

-Retained uterine products of conception

What is the gold standard study for diagnosing bladder rupture?

-Retrograde cystography. -CT scan of the pelvis with passive filling of the bladder with contrast is inadequate for evaluation of bladder injury. Muscular bladder wall can seal & prevent leakage of contrast material through the defect unless the bladder is sufficiently distended.

What do you do if you use fentanyl and it leads to chest wall rigidity?

-Reverse it with an opioid antagonist and positive-pressure ventilation.

What is presentation of Tick Paralysis? What is Tx?

-Reversible, rapidly ASCENDING PARALYSIS Similar to Guillain-Barré, but no paresthesias Treatment: Find and remove the tick take hours to improve

Child presents with rapidly worsening altered mental status, n/v, and then has seizure. His LFT's are all markedly elevated. He just recovered from chicken pox a week ago. What is the diagnosis?

-Reye syndrome: - Rapidly progressive encephalopathy with hepatic dysfunction, which often begins several days AFTER apparent recovery from a viral illness, especially varicella or influenza A or B -Characterized by vomiting and confusion, rapidly evolving to seizures and coma

Which disorders cause pericardial effusions?

-Rheumatologic disorders -Chest malignancies -TB -Cardiac chamber perforation -Proximal aortic dissection to name a few.

What is RhoGam & what does it do? What disease process does it prevent? What are the indications for giving RhoGam? What is dosing?

-RhoGAM = IgG anti-D antibodies -Destroy Rh+ fetal red cells in the maternal circulation If RhoGAM not given, mother develops antibodies to Rh+ fetal blood which cross the placenta and cause a HEMOLYTIC ANEMIA IN FETUS , splenomegaly, erythroblastosis, death Indications: Rh- and abortion (any type), abruption, ectopic, antepartum hemorrhage, trauma (even relatively minor) in boards ALL GET RHOGAM ON BOARD EXAM. Dose: 50 mcg if <12 weeks, 300 mcg if >12 weeks

What are the most common associated injuries with sternal fractures?

-Rib fracture and pulmonary contusion

What is profile of ricin toxicity from inhalation vs ingestion?

-Ricin is a toxin naturally found in castor beans that disrupts protein synthesis. -By inhalation ricin may cause respiratory distress, fever, cough and pulmonary edema. within 8 hours. -Ingestion of ricin can lead to symptoms of vomiting, bloody diarrhea and dehydration within 6 hours. In severe cases, MOSF can occur. -Ricin used in pellet by Bulgarian secret police to kill a dissident. -No proven antidote. -Supportive care and possible gastric lavage and activated charcoal. -Decontamination procedures should be undertaken for skin because ricin causes burns.

How is ricin toxin acquired, and what is main problem?

-Ricin: Cytotoxin, castor bean mash, inhalation; airway necrosis, fever, cough, sweating,HEMORRHAGIC PULMONARY EDEMA; ELISA; -TX: is supportive

What AMI complication presents as triad of hypotension, JVD and clear lungs?

-Right ventricular infarction -Associated with inferior MI -Do right sided chest leads (especially V4R) looking for ST elevation -Use NTG and morphine WITH CAUTION (can drop BP precipitously) -Use fluids liberally to augment preload as long as lungs CTA, NO pressors. PUSH FLUIDS

What are risk factors for accidental hypothermia?

-Risk factors: -Extremes of age -AMS for any reason -Burns -Trauma

What % of dehydration is in child with below sx's? Mild (3%), Moderate (6%), Severe (9%)? -Dry mucous membrane -Delayed capillary refill -Sunken eyes -Decreased skin turgor -Elevated heart rate -Tachypneic -Decreased BP -Lethargic

-Severe >9% -Tx: 20 ml/kg NS IV.

What are signs and symptoms of a strangulated inguinal hernia?

-Severe pain -Skin discoloration -Fever -Strangulated hernia = acute surgical emergency - get a surgical consultation & start antibiotics.

What is hallmark of testicular torsion?

-Severe, sudden-onset scrotal pain with radiation to the abdomen

Always consider _______________________ in all cases of pediatric vulvovaginitis and retained vaginal foreign body.

-Sexual abuse

What is the clinical presentation of acute pericarditis?

-Sharp pleuritic chest pain that improves with sitting up.

What are the 3 EKG findings for WPW?

-Short PR interval -Delta wave -Slightly wide QRS

What is plain film radiological difference between sigmoid volvulus vs cecal volvulus?

-Sigmoid volvulus: (Sigmund Freud loves sipping coffee while laying on bent inner tube in river.) --He is an old man. -Occurs in old people age 60 to 70 years. -"coffee bean sign" or "bent inner tube." -Sigmoid is displaced from the left iliac fossa and points upward towards diaphragm -Barium enema: "Bird's beak" sign -Cecal volvulus: -"Kidney bean sign" -Cecum is displaced medially and superiorly, resulting in seeing small bowel in the right iliac fossa rather than large bowel. https://youtu.be/KLQRoGOXMMg

What are clinical features of bacterial tracheitis?

-Signs of airway obstruction: -Stridor -Cough -Respiratory distress. -Fever (drooling is uncommon.) -Toxic with high fever and a rapidly progressing croup-like syndrome. -Nebulized epinephrine and steroids ineffective! -Patients prefer to lie flat.

What is Sickle Cell Vasoocclusive Crisis? What is most common presentation?

-Sludging of sickled RBCs causing microcirculation obstruction, ↑ viscosity, ischemic pain, infarction Precipitants: any stress: -Infection -Cold exposure -Dehydration -High altitude -Exertion -Musculoskeletal pain: most common presentation (arm, leg, low back)

What are lacunar syndromes, and what is their prognosis compared with cortical strokes?

-Small, deep penetrating vessel disease -Microinfarcts infarction in HTN/DM patients -Stuttering course -Often CT scan negative -Prognosis better than with cortical strokes

What are predisposing factors for peptic ulcer disease?

-Smoking -ETOH -NSAIDS -Steroids -Zollinger Ellison syndrome [secretion of gastrin by duodenal or pancreatic neuroendocrine tumors (gastrinoma)]

What is difference of FeNA, urine Na+, and Bun/Cr ratio in pre-renal vs renal failure?

-So the way body holds in water is holding onto Na+, so this will be low in urine if kidney if functioning normally. When kidney is in intrinsic failure then kidney loses Na+

What is the periodontal ligament?

-Soft tissue that maintains the tooth in position

What type of bleed is octreotide used for?

-Somatostatin analogue and splanchnic vasoconstrictor -Indicated for variceal bleeding

What is the most sensitive sonographic finding in acute cholecystitis?

-Sonographic Murphy sign

What are the sonographic findings of acute cholecystitis?

-Sonographic Murphy sign -Gallbladder wall thickening -Cholelithiasis or sludge -Pericholecystic fluid.

What is agoraphobia?

-Specific fear of open or public places

Of all skull fractures, what part of skull is the most likely to be associated with intracranial bleeding in infants and young children?

-Temporal bone due to the underlying cerebral vasculature (middle meningeal artery).

Young adult female presents with yellow-green, frothy, malodorous vaginal discharge; pruritus, irritation, &abdominal pain: On pelvic exam she has a "Strawberry" cervix. What is dx and tx?

-Trichomoniasis vaginitis -Diagnosis: Wet mount (motile trichomonads), spun urine, cultures -Strawberry" cervix = Punctate submucosal hemorrhages Tx: Metronidazole or tinidazole (single dose), topical not recommended ***Disulfiram-like reaction with alcohol

What is erysipelas, and how does it present?

-Think: Superficial cellulitis, lymphangitis -Localized (face, legs, ear) Butterfly facial rash (warm and tender) -Group A Strep, occasionally Staph Raised, well demarcated border -TX: PCN, dicloxacillin, erythromycin

What is first-line treatment of SBP?

-Third-generation cephalosporin (cefotaxime)

What is Type II Decompression Sickness?

-This is Any kind of neurol finding after diving -CNS decompression sickness -High CNS concentration of nitrogen -Prickly sensations in the limbs -Low back and abdominal pain -Spinal DCS: Limb paresthesias, weakness Dermatome sensory distribution is common Incontinence, priapism Headache, diplopia, dysarthria, inappropriate behavior -Differs from arterial air embolism because sx's develop GRADUALLY HOURS AFTER SURFACING (unlike arterial gas embolism which manifests <10 mins of surfacing) -DCS of the lungs = "The chokes" -Decompression shock = Vasomotor DCS -DCS involving cerebellum or inner ear = "The staggers" Sx's the same as inner ear barotrauma -Cause: Gas bubbles in inner ear or cerebellum

What is the typical presentation of MFS (Miller Fisher Syndrome)?

-This is a GBS variant. -Ophthalmoplegia with ataxia and areflexia -Some will develop some extremity weakness, linking this disorder to GBS. -Incomplete forms include acute ophthalmoplegia without ataxia, and acute ataxia without ophthalmoplegia

At which levels do bilateral facet dislocation most likely to occur?

-Thoracic and lumbar spine - much more common due to the relatively larger articular processes. -Unstable and typically present with neurologic deficits

What is patient profile of those with PRES?

-Those prone to sharp spikes in blood pressure: -Eclampsia -Kidney disease -On immunosuppressive therapy, such as those with autoimmune disease and transplanted organs. -Patients with diabetes and malignancies

At what level of platelet count do you start treatment for ITP? What is treatment for ITP?

-Thresholds for treatment -If no active bleeding: Platelet count of 20-30,000 -If actively bleeding: Platelt count 30-50,000 Major concerns = ICH (especially in the elderly) -TX: -SUPPRESS the immune response first with prednisone -REPLACE platelets with 2-3 times the calculated amount to get to 50,000 -High-dose RhoGAM (anti-D immune globulin) works within hours / CAN ONLY GIVE to Rh+ patients (more effective / fewer side effects than IGG) Is more efficacious and expensive than steroids -Spleen destroys antibody-coated Rh+ red cells and, in the process, destroys fewer platelets "Bait & Switch

What are key risks for patients with nephrotic syndrome?

-Thromboembolic events -Severe infection.

What is most common cause of ischemic strokes, thrombotic or embolic?

-Thrombotic (most common)

How is rabies spread?

-Through the saliva of an infected animal. -A person is not considered at risk if no animal saliva exposure to mucous membranes. -Exposure to animal blood, urine, or feces are not risks for contracting rabies.

For a felon on the thumb and fifth finger where do you make the incision to drain the abscess? What about for a felon on second, third, or fourth fingers?

-Thumb and fifth finger are incised radially -Second, third, and fourth fingers are incised on the ulnar side to avoid the sensate finger pad and areas most vulnerable to contact.

Which fingers are the most important digits in terms of hand function?

-Thumb and index fingers

What are late findings of mesenteric ischemia on plain radiographs?

-Thumbprinting with multiple round soft tissue densities appearing in the intestinal lumen from edema and hemorrhage. -Pneumatosis intestinalis and portal venous gas, which occur with bowel infarction. http://reference.medscape.com/features/slideshow/mesenteric-ishchemia-radio-signs

Mass in anterior mediastinum: 4 'Terrible T's'

-Thymoma (consider myasthenia gravis) -Thyroid (retrosternal) -Teratoma/germ cell (teeth, hair, etc.) -"Terrible" lymphoma

IV contrast may cause what endocrine emergency?

-Thyroid storm -Other causes: -Any stressor can cause thyroid storm

What sort of arrhythmias is magnesium used to treat?

-Treats specific subset of ventricular tachycardias: 1) Torsade de pointes 2) Long QT-interval-associated VT 3) Digitalis toxicity 4) Post-MI ventricular arrhythmia.

Patient has had his feet in cold, wet blizzard for 3 days. He complains of bilateral feet pain after he rewarmed them. On exam the feet are mottled, anesthetic, & pulseless. What is diagnosis?

-Trench foot / immersion foot Prolonged wet feet Mottled, anesthetic, pulseless foot Severe pain upon rewarming/reperfusion -Hyperhidrosis and cold sensitivity may occur late and may persist

What is Wegner glomerulonephritis, and how is it different from poststrep glomerulonephritis?

-Triad: 1) Sinusitis 2) Pulmonary infiltrates 3) Glomerulonephritis. -Difference from poststrep glomerulonephritis is that Glomerulonephritis and hematuria are rare at presentation.

Infant heart has complete absence of the tricuspid valve, a hypoplastic right ventricle, and the presence of a VSD. What is diagnosis?

-Tricuspid atresia -Because the left ventricle is the only functional chamber, fluid overload easily occurs, causing CHF and hepatomegaly in the infant.

ECG findings seen after ingestion of __________ shows tachycardia, QRS prolongation, and a prominent R wave in aVR.

-Tricyclic antidepressants -sodium channel-blocking agents

What is a STEMI?

-1mm ST elevation in 2 contiguous leads

How many volts are involved in lightning Injuries?

-50,000 volts

What is most common caused of urethritis in U.S.?

-Chlamydia trachomatis.

What are the most common mechanisms of injury in SCIWORA?

-Flexion and extension

Vesicles grouped on digits. What is diagnosis?

-Herpetic whitlow

What is the treatment of closed clavicle fractures?

-Ice -NSAIDs -Sling

What are complications of heparin, and how do you reverse it?

-Bleeding -Decreased platelets -Reversed by protamine

What are the 3 things needed in calcium metabolism?

-PTH -Vit D -Kidneys

What ingestion is associated with most toxic iron incidents?

-Prenatal vitamin ingestion

What the most common cause of acute AR?

-Valvular incompetence

What is most common cause of acute mesenteric ischemia?

-SMA occlusion (Superior mesenteric artery)

1st line tx: Permethrin cream, ivermectin 2nd line tx: Lindane lotion (not first line, age >2 yrs)

-Treatment for scabies.-

What condition is a severe infection of the deep structures of the eye that usually follows cataract or other eye surgery or penetrating trauma?

-Endophthalmitis

What lab test must you check before starting DABIGATRAN (PRADAXA)?

-Excreted by the kidneys so check renal function b/4 start this.

What are causes, sx's, and treatment for hypermagnesemia?

-Causes: Renal failure, iatrogenic -Sxs: HYPOREFLEXIA, Weakness, RESP DEPRESSION, heart blocks TX: IV calcium (the same as with hyperkalemia), dialysis

What is the most common viral culprit identified in developed countries in myocarditis?

-Coxsackievirus

What is the most common complication of necrotizing external otitis?

-Cranial nerve 7 paralysis.

Patient presents with chest pain radiating to trapezius. --Increases with inspiration and swallowing and has dysphagia Patient has relief of chest pain upon sitting up & bending forward -Fever What is the diagnosis?

-Acute pericarditis

What are presentation features suggest aortic dissection?

• Tearing chest pain radiating to the back • History of poorly treated hypertension • Extremely elevated blood pressure • Upper extremity paresthesia Any one of these above features is not particularly suggestive of aortic dissection but, overall picture, should make one consider aortic dissection. -Hypertension is a risk factor for aortic dissection.

What are the 6 types of bacterial toxigenic causes of diarrhea (Think food poisoning)? Of these which is the most common cause of food-born diarrhea and which one is the most common cause of traveler's diarrhea?

"CBS SEV" -Clostridium perfringens -Large outbreaks -buffets, schools -Casseroles, stews, gravies, steam table meats TX: IVF (abx not helpful) -Bacillus cereus -fried rice (Chinese restaurants) 2 types: -"Violent vomiting": 2-3 hours post ingestion (much like Staph) -Diarrheal - 6-12 hrs later like C. Perferingens Tx: supportive -Staph- Most common cause of food-borne disease -Large outbreaks, potato salads, cream-filled pastries -within 6 hours of ingestion Tx: supportive -Scombroid poisoning = sushi =Deep ocean fish (tuna, mackerel, mani mahi) not promptly refrigerated -Tastes "peppery" -Histamine-like toxin, rapid onset -30 minutes -Facial flushing, palpitations, diarrhea, throbbing headache, abdominal cramps -TX: Give antihistamines -E. coli (toxigenic) - The most common cause of traveler's diarrhea -Pepto Bismol prophylaxis TX: Bactrim, ciprofloxacin -Vibrio cholera - "rice water" diarrhea -Severe fluid and electrolyte problems -TX: WHO rehydration, ciprofloxacin, TMP-SMX -Foodborne -Fast onset and fast offset from bacterial enterotoxins -Watery and voluminous -No WBCs or RBCs in stool because it's not invasive

What are the 6 forms of invasive diarrhea? Which of these is the most common cause of bacterial diarrhea?

"CHESSY V" -Campylobacter - Most common cause of bacterial diarrhea, backpacker's diarrhea a trigger for Guillain-Barré syndrome*** Cipro -Hemorrhagic E. coli 0157:H7 gross blood in stools, Cause HUS in children & TTP in elderly, ABX increase risk of HUS -Shigella -High fever, febrile seizures - cipro -Salmonella - pet turtles, amphibians, egg - cipro -Yersinia enterocolitica: Gram negative bacterium ***MIMICS APPENDICITIS Tx with cipro -Vibrio: -Parahaemolyticus: raw oysters, clams -Vulnificus: oysters, shellfish; increased morbidity with preexisting liver disease, bad wounds with sea water Cipro or doxy

What are the 3 protozoans causing diarrhea?

"GAC!" -Giardia - Most common cause of water-borne diarrheal outbreak in US, "backpacker's" diarrhea borborygmi(grumbling stomach), floating, frothy, foul-smelling stools TX:Metronidazole -Amebiasis (Entamoeba histolytic) in Mexico/Central America -Spreads to: (Brain, lung, heart, liver), liver abscess, pericarditis, pleuropulmonary disease, cerebral amebiasis TX:Metronidazole + Paromomycin -Cryptosporidium-Most common cause of chronic diarrhea in AIDS -Animal handlers, immunocompromised -Nitazoxanide, if cannot tolerate nitazoxanide then give Paromomycin(non absorbable aminoglycoside) (Humatin) plus azithromycin

What does ITP stand for? What is ITP? What is difference between pediatric and adult version?

"I" of ITP = immune or idiopathic Thrombocytopenic Purpura -Immune destruction of platelets usually triggered by an unknown (idiopathic) antigen -Low platelet count with no other causes -PEDIATRIC version -Peak age, 5 y/o, both sexes equally -Sudden onset of petechiae or purpura several weeks after an infectious illness -Most cases resolve within six months -Do well without treatment -ADULT version -Insidious onset / chronic duration / -Mostly women -Runs in families

Why does von Willebrand disease cause GI and cutaneous bleeding?

"VW bug carries 8 passengers!" Mnemonic. -von Willebrand factor is a carrier protein for factor VIII and acts as a cofactor for platelet adhesion. - Absence of von Willebrand factor causes a decrease in platelet adhesion and clinically appears similar to hemophilia A.

What is definition of postpartum hemorrhage, and what are the 2 types?

- >500 mL of blood in 24 hours following vaginal delivery. -2 types: -Early = <24 hours after delivery -Late = >24 hours to 6 weeks after delivery

How do you diagnose thyroid storm?

- A clinical diagnosis -Hallmark is CNS dysfunction -Other diagnostic criteria include -Temp > 38 ˚C -Tachycardia out of proportion to the fever -Exaggerated peripheral manifestations of thyrotoxicosis, including tremor and weakness

What is acute cerebellar ataxia in children?

- A postinfectious condition that occurs about 2 weeks after a viral illness. -The most common cause of ataxia in children. -Found in more than one-third of cases of pediatric ataxia -More common in children < 6 years.

What is Wellens syndrome, and why is it critical to recognize?

- AKA LAD coronary T-wave syndrome -Refers to these specific electrocardiographic (ECG) abnormalities in the precordial T-wave segment associated with critical stenosis of the proximal left anterior descending (LAD) coronary artery. -Most common of the 2 forms, which occurs 76% of the time, is deep inversion of the T-wave segment in the precordial leads -Less common of the 2 forms of Wellens syndrome, which occurs in 24% of patients, consists of biphasic T waves (see the images below), most commonly in leads V2 and V3

What is 4 pronged tx for PUD?

- Antibiotics against H. pylori (amox, flagyl) - H2 blockers 4 weeks - Proton pump inhibitors (omeprazole) - Surface protectants (sucralfate)

What are 3 complications of PUD?

- Bleeding - Perforation (can cause pancreatitis) - Gastric outlet obstruction

What is an electrical storm?

- Cardiac electrical instability: - Multiple episodes of VT or VF within short period of time (24 hours)

What is profile of child with bacterial tracheitis?

- Child <8 y/o. -Has purulent secretions of tracheal mucosa below the vocal cords caused by bacterial infection. -Staphylococcus aureus is the most common cause.

When you apply magnet to pacemaker, and what happens when you do this?

- For Pacemaker failure -Apply magnet over PM to turn off sensing function → temporarily converts PM from demand to fixed rate Allows assessment of whether PM function is intact, whether capture is present, and if battery is working -Should also Assess for electrolyte abnormalities in pacemaker failure.

How do you diagnose slipped capital femoral epiphysis?

- Frog leg view of pelvis: Klein's line can be drawn from the lateral aspect of the femoral neck toward the capitulum. -Normal finding -Klein's line intersects some portion of the epiphysis. If it does not, SCFE is the diagnosis. -"melting ice cream cone"

How do you diagnose giant cell arteritis?

- Has 3 of 5 criteria: -Age ≥50 -ESR ≥ 50 -Temporal tenderness or decreased temporal artery pulse -New-onset headache -Abnormal biopsy.

How does prion disease present?

- Has neurocognitive deficits like all neurocognitive disorders -DISTINCTION: -Ataxia (& Huntington-like sx's) -Myoclonus -Dystonia -Chorea. -includes spongiform encephalopathies such as kuru, bovine spongiform encephalopathy ("mad cow" disease), and Creutzfeldt-Jakob disease. -Progress rapidly and at any age.

Most clavicle fractures involve the ________ of the bone.

- Middle third of the bone.

Why do open fractures of the mandible, orbit, and frontal bone require antibiotic prophylaxis?

- Open Mandible fx is exposed to mouth flora. -Rest of the other fx's are exposed to sinus and the associated flora.

What is pathology of prerenal failure, and what is most common cause? What is treatment?

- Shock (↓ Perfusion) = Decrease in renal flow -Hypovolemic (most common) -Cardiogenic -Distributive TX: -Restore circulating volume -Fluids -Pressors

How do you treat acute arsenic toxicity?

- Skin decontamination -Chelation with: -Dimercaprol (British Anti-Lewisite, or BAL) --meso-2,3-dimercaptosuccinic acid (DMSA, succimer)

How do you calculated pseudohyponatremia?

- ↓1.6 mEq/L for every 100 mg/dL ↑ glucose over 100

What is Necrotizing fasciitis?

-"Flesh-eating" bacteria -Strep, clostridia, polymicrobial "Pain out of proportion" is hallmark Surgical emergency -Pen G + imipenem, or amp + gent + clinda Fournier's gangrene: Necrotizing fasciitis involving scrotum, vulvar or perianal skin

What are the clinical manifestations of myocarditis?

-"Flu-like" illness- Misdiagnosed as flu -Fever, sinus tach (out of proportion to fever) -Symptoms of CHF in young person -Lab: elevated troponin

Charcoal is contraindicated for what ingestions type of ingestions?

-"No AC for MACC!" -No Activated charcoal for Metals, Alcohols, Caustics and Cyanide.

What are CT abdominal findings indicative of intussusception in adult?

-"Target sign"- alternating hypo/hyperdense layers, indicative of intussusception -"Bulls-eye" lesion

What is Disseminated intravascular coagulation, or DIC?

-"They clot then they bleed." -AKA "consumptive coagulopathy" -An EXTRINSIC pathway problem (vs dilutional) -Activation of the coagulation system ------> micro-thrombosis-------->consumption of coagulation factors and platelets. Then activation of the fibrinolytic system -------> fibrinolysis → fibrin degradation products and d-dimer--------> causes bleeding.

What is difference between "valvular AF" & "non-valvular AF?"

-"valvular AF" refers to patients with mitral stenosis or artificial heart valves -"non-valvular AF" may have other types of valvular heart disease or any other cause of AF eg. HTN, hyperthyroidism

What is SUID (SIDS)?

-(CDC) defines SUID as death of an infant < 1 year of age that occurs suddenly and unexpectedly, and whose cause of death is not immediately obvious before investigation. -Most common between 2 and 4 months of life.

What is classic presentation of adult with botulism? What is the most common early finding? How is sensory exam affected? What is treat

-***Bulbar with descending paralysis with anticholinergic sx ***Impairs motor and autonomic function -Nausea, vomiting and diarrhea (foodborne) ? -Bulbar symptoms - diplopia (the most common early finding), ptosis, dysphagia, dysphonia, dysarthria -Descending flaccid paralysis -Anticholinergic symptoms (dry mouth, urinary retention, dilated pupils, ileus, decreased tears) -Sensory exam and mental status are normal Treat with antitoxin if suspected Wound botulism Antitoxin Wound debridement High dose Penicillin

What is treatment of multifocal atrial tachycardia?

-***Treat underlying condition -MgSO4 may be helpful; no shocks! 2 arrhythmias don't shock: MAT and S. Tach

At what week of pregnancy does urine pregnancy test turn positive? When a pregnant woman's fundus is at the umbilicus what gestational week is the mother ?

-1-2 weeks gestation = + Upreg Fundus at umbilicus = 20 weeks gestation.

What is the danger with oral commissure burns?

-10% severe labial artery bleed, after 5 days -Recommend admission -Outpatient: reliable parents, can control bleeding

1 unit of platelets will raise platelet count by ___________.

-10,000 -A platelet pheresis pack contains 6 units of platelets and is from a single donor -Give ABO-compatible platelets

What is dose of adenosine for pediatric stable SVT?

-100 mcg/kg (0.1mg/kg) and double the dose if the tachyarrhythmia doesn't resolve.

Describe the correct placement of the Sengstaken-Blakemore tube.

-1st intubate patient to prevent aspiration. -The correct placement is accomplished with the large balloon advanced completely into the stomach. -Confirm positioning of gastric balloon with imaging or by auscultating over the stomach while inserting air in the gastric port. -Initially inflate gastric balloon with 250 mL of air so that it abuts securely against the gastroesophageal junction. -Then inflate esophageal balloon if bleeding persists. Inflate esophageal balloon to no more than 50 mm Hg to control esophageal variceal bleeding. https://youtu.be/NHelCd5Jtp4

What DDX should you consider in sick patients with pyelonephritis - especially in diabetics?

-2 Surgical complications a)Perinephric abscess -Different from renal abscess or carbuncle, which is from hematogenous spread b) Emphysematous pyelonephritis High mortality.

What bacteria causes toxic shock syndrome?

-2 toxin-producing bacteria -Staphylococcus aureus -Streptococcus pyogenes.

What is endometritis, and what are the risk factors for this infection?

-A polymicrobial infection of the uterus 3 to 5 days following delivery -Characterized by: -Foul loch -Fever -Pelvic pain -Uterine tenderness. -Risk factors: (Any condition that prolongs the period of exposure of the unprotected endometrium to the vaginal canal can lead to endometritis) -Retained products of conception or placenta -C-section -Young maternal age -Lower socioeconomic status -PROM -Frequent vaginal examinations -Use of intrauterine monitoring devices

How do patients present after struck by lightning? Why is the pupil exam unreliable?

-2/3 present with lower extremity paralysis -2/3 - permanent sequelae -Deep burns, extensive tissue damage, renal failure rare (unlike electrical injury) -Massive DC electrical shock, brief duration, passes over body, deep injury rare -Ruptured TM (Type I blast injury) -Motor paralysis -Pupils unreliable (paralysis of the iris) -Diaphragm paralysis, so heart is asystole, but starts back up, but still diaphragm still paralyzed so then can die of hypoxia. -Hypoxia -Cardiac arrest Initial asystole → recovers (automaticity) -Diaphragm may be paralyzed longer than heart -Respiratory arrest can outlast cardiac arrest, so have hypoxia → death -Early: CPR rather then cardioversion (AED) -Support ventilation -TM perforation and cataracts are common -50% of pregnancies have fetal demise -Permanent cognitive and motor sequelae common

What is definition of flail chest?

-3 or more adjacent ribs fractured in two or more places.

What problems do patients with tertiary syphilis have?

-3-25 years after infection (immunocompetent) -If I contracted syphilis while in Vegas for board review then when I return in 10 years for taking review course again I will get dementia and torn up aorta and gummas. -Cardiac and neurologic sequelae. --Neurosyphilis = Dementia, meningitis -Aortic aneurysm -Gumma of skin -Charcot joint disease

How many compartments is the mediastinum divided into?

-3: anterior, middle, posterior compartments

What trimester does uterine perforation occurs most commonly due to both blunt and penetrating trauma?

-3rd trimester when the uterus is relatively exposed

Infuse _____________ of contrast material into the adult bladder to reduce the possibility of a false-negative result for bladder injury.

-400 mL

In a patient with radiation exposure, how does 48 hour absolute lymphocyte reflect prognosis?

-48 hour absolute lymphocyte count (cells most affected) -> 1200 (very good) 300-1200 (possibly lethal) -< 300 (lethal)***KNOW

What are the 5 Ps (paroxysmal spells) of pheochromocytoma?

-5 Ps (paroxysmal spells) in a 20-45 y/o patient -Pressure (sudden increased hypertension) -Pain (headache, chest pain, abdominal pain) -Perspiration -Palpitations -Pallor

Contraindications to succinylcholine use

-5 risks for hyperkalemia only after 5 days & Rxn, Neuro& drugs: 1) Burns covering more than 10% BSA 2) Crush injuries 3) Strokes 4) Spinal cord injuries 5) Intraabdominal sepsis -History of malignant hyperthermia -Neuromuscular diseases(AML, MS) (up regulation of ACH receptors) -Recent cocaine or amphetamine use (inhibits plasma cholinesterase)

Child presents with tiny papules on erythematous base, of face, but eyelids and chin are spared. Child has sickle cell and CBC shows acute drop in hemoglobin. What disease does child have?

-5th disease think 5 fingers on hand=slap face (slapped cheeks), tiny papules on erythematous base, eyelids and chin spared -Parvovirus B19 -Complications: Arthritis, aplastic crisis (especially in ticklers) -Fetal anemia if acquired during pregnancy

What are the 6 H's and T's of cardiac arrest?

-6 H's: -Hypoglycemia -Hypothermia -Hypovolemia -Hypoxia -Hypo/hyperkalemia -Hydrogen -6 T's: -Tension ptx -Tamponade -Thrombosis of lung (PE) -Thrombosis of heart (ACS) -Trauma -Toxin

Children younger than ______ months are obligate nose breathers.

-6 months

How sensitive is Head CT in detecting subarachnoid hemorrhages?

-95% sensitive in detecting subarachnoid hemorrhages -Almost 100% for patients who undergo imaging within 6 hours of headache onset.

What do you look for on peritoneal fluid analysis for infection? What is the most common bacterial cause of infected peritoneal fluid from CAP?

->100 WBCs/mm3, >50% PMNs (lower threshold than normal SBP because have CAPD) S. epidermidis (#1) S. aureus, Strep. and gram negatives

What is Frontotemporal neurocognitive disorder?

-A common cause of dementia in patients younger than 65 years. -Associated with disruptive behavioral changes more prominent than the other cognitive impairment. -Hyperorality, wandering, and disinhibited behavior -Median survival after diagnosis of frontotemporal neurocognitive disorder is 3 to 4 years

What is Torsades de pointes (TdP)?

-A form of polymorphic ventricular tachycardia (VT) occurring setting of acquired or congenital QT interval prolongation

What is Korsakoff syndrome (KS)?

-A late, neuropsychiatric manifestation of Wernicke encephalopathy (WE) in which there is a striking disorder of selective anterograde and retrograde amnesia. -Marked anterograde and retrograde memory deficits -Apathy -Intact sensorium and other cognitive skills. One alcoholic poet passed an hour with me reciting flawlessly the works of Wordsworth, but had no recollection of our meeting one minute after I stepped out of the room. -Confabulation in some but not all cases. -AMNESIA and CONFABULATION (invented memories which are taken as true due to gaps in memory) -Affected subjects carry on a socially appropriate conversation that may seem normal. -Patients with KS are unaware of their illness.

What is NMS (Neuroleptic malignant syndrome)? How does neuroleptic malignant syndrome present? What is TX of NMS?

-A life threatening neurologic emergency associated with the use of neuroleptic agents. -Develops over days to weeks -Neuroleptics (Anti-psychotics) example: -Haldol -Risperidone -Chlorpromazine (Thorazine) -Metoclopramide -Promethazine Mnemonic ("FEVER") -Fever -Encephalopathy -Vital sign instability (tachycardia, labile BP) -Elevated CPK -Rigidity "Lead pipe" -TX: Dantrolene or bromocriptine

What is carpal tunnel syndrome, and what are the symptoms?

-A median mononeuropathy -Most common entrapment mononeuropathy in the body. -Classic symptoms: -Pain and paresthesias on the volar side of 1st, 2nd, & 3rd fingers & radial half of 4th finger -Symptoms most noted at night.

When do you consider a conversion disorder?

-A patient who has a motor or sensory deficit and you can't identify a physical cause.

What is advantage of using fenoldopam in HTN emergency?

-A peripheral dopamine-1 receptor agonist -Unlike other parenteral antihypertensive agents, maintains or increases renal perfusion while it lowers blood pressure -Beneficial in patients with renal impairment

What is reactive arthritis?

-A postinfectious arthritis often develops following dysentery (Diarrhea caused by the invasive GI bacteria, Campylobacter, Salmonella, and Shigella, and Yersinia) or a chlamydial infection. -Presentation: an asymmetric polyarthralgia that typically affects weight-bearing joints. -formerly referred to as Reiter syndrome) includes arthritis, urethritis, and uveitis. But this is only a subset of reactive arthritis.

What can affect the tolerance of feeding or even secretions in neonates?

-A tracheoesophageal fistula. A congenital fistula is most often associated with esophageal atresia (85%), and because of this combination, patients present for evaluation early in the neonatal period.

What blood type carries the highest risk of causing an acute hemolytic reaction in an uncrossmatched blood transfusion?

-AB-negative blood. -Has both A and B antigens on the red blood cells

What is clinical presentation of aortic dissection for board exam?

-ABRUPT tearing chest pain, radiation to back -MAXIMAL intensity at onset -MIGRATING dynamic pain pattern -Aortic insufficiency -Pulse deficits - ACUTE PARALYSIS, Syncope, decreased LOC, -THINK: CP&murmur or CP and pain below diagphragm or paralysis = dissection

Which type of electrical injury is worse, AC or DC?

-AC(tetany) three times worse than DC -AC: exit = entrance (held) are same, AC = Tetany -DC: exit > entrance (thrown) DC throws you back like DC comic superhero mnemonic

What is history of acute angle-closure glaucoma? What is the IOP? What precipitates acute angle-closure glaucoma? What is classic exam of acute angle-closure glaucoma? Is acute angle-closure glaucoma considered a medical emergency? What are the 3 meds to tx it?

-ACUTELY painful Red eye -Sudden in onset with loss of vision. -Elevated intraocular pressure (>40) Normal range 10-21 mm Hg Mydriatics may precipitate it Dim light (dilated pupil) may precipitate it Exam: -Fixed midpoint pupil -Steamy, clouded, or hazy cornea, with a mid-dilated pupil unreactive to light. -YES! Requires emergent ophthalmology consultation. -Initial medical management: -First lower the intraocular pressures -Timolol then -Acetazolamide IV/PO -Alpha-agonists (apraclonidine) -Then constrict the pupil to promote drainage - Pilocarpine **** should be used AFTER the IOP is decreased Emergent ophthalmology consult (****call before you give the pilocarpine) -Mannitol IV: 1 gm per kg Osmotically decompresses the eye

What problems cause narrow anion gap, specifically what 2 types of toxicities cause decreased anion gap?

-AG < 3 -Hypoalbuminemia (less unmeasured anions) (Think nephrotic syndrome) -Multiple myeloma (excess positively charged IgG paraproteins), -3 hypers - Hypercalcemia, Hyperkalemia, Hypermagnesemia, -Lithium toxicity -Bromide intoxication know this (mistaken for chloride) Can get negative Anion Gap with Br poisoning!

What is Late post-MI myopericarditis?

-AKA Dressler syndrome -Occurs few weeks after large acute MI. -Presents with: -Pleuritic chest pain -Fever -Leukocytosis -Pericardial friction rub. -ECG findings are similar to pericarditis with diffuse ST-segment elevation and PR segment depression without reciprocal change of both the PR and ST segments.

What is dry socket?

-AKA Postextraction alveolar osteitis -A common complication after the extraction of impacted wisdom teeth. -Caused by displacement of the clot from the socket that exposes alveolar bone and results in a local osteomyelitis

What is Sheehan syndrome?

-AKA postpartum hypopituitarism -Rare complication of postpartum hemorrhage -Pituitary gland is enlarged in pregnancy and sensitive to infarction from hypovolemic shock. -Definition: Ischemic necrosis of the pituitary gland occurring following maternal hemorrhage and hypotension in peripartum period -Affects secretion of one, several, or all of its hormones. -Common presentation is failure to lactate post delivery (agalactorrhea) and amenorrhea or oligomenorrhea. -Leads to: -Hypopituitarism -Hypothyroidism -Adrenal insufficiency -Amenorrhea

What is conversion disorder?

-AKA: -Functional neurologic symptom disorder, -Psychogenic disorder -Hysterical neurosis -Pseudoneurologic syndrome -A somatoform disorder involving persistent physical symptoms with no identifiable physical cause. -Often associated with a recent trauma or stressor -Involves one or more motor or sensory symptoms incompatible with recognized neurologic or medical conditions. -Produced unconsciously

V. Tach vs Wide complex SVT

-ALWAYS assume a regular WCT on the boards is Vtach

Upper and lower motor neuron degeneration is the cause of ______________________.

-AML, amyotrophic lateral sclerosis, AKA Lou Gehrig Disease. -rapidly progressive weakness and atrophy of the muscles. -Loss of reflexes and spasticity

What are hallmarks of myxedema coma?

-AMS & hypothermia -Also has: -Hypotension -Bradycardia -Hyponatremia -Hypoglycemia -Hypoventilation are often present

How is a coin oriented on X-ray when in trachea vs esophagus?

-AP orientation: coin in trachea (same plane as vocal cord orientation- sagittal) -Transverse orientation: coin in esophagus

Patients who have been exposed to pulmonary irritants might not develop _________________ for 24 to 36 hours.

-ARDS symptoms

What are the most important complications of pancreatitis?

-ARDS, DIC, renal failure

What is pathology of acute renal failure? What are the 4 main causes of ARF, and which one is the most common?

-ARF = Intrinsic Disease = Damage to kidney structures -Causes: 1) Vascular Dissection, Thrombosis, Emboli 2) Glomerular Glomerulonephritis (GN) 3) Interstitial Acute Interstitial Nephritis (AIN) 4) Tubular (most common) Acute Tubular Necrosis (ATN)

What medications are contraindicated in pregnancy?

-ASA -NSAIDs (3rd trimester) -Tetracycline -ACE inhibitors -Aminoglycosides -Warfarin (Coumadin) -Live vaccines (MMR) -Ergot alkaloids

What is presentation of gout or pseudogout?

-Acute mono arthritis -Most commonly the great toe or the knee -Precipitated by: -Alcohol -Diet of meat and seafood (high in urates) -Infection -Trauma -Stressors.

What are physical effects of acute cerebellar ataxia in children?

-Acute onset -Wide-based gait disturbance predominates -Truncal effects are more pronounced than those on the extremities.

When is the only time you tx asymptomatic bacteruria, and why? What are the 2 causes of sterile pyuria, and which one is the most common cause? What do you call sterile urine with dysuria, and what is DDX? If this occurs in men, then how do you tx?

-ASYMPTOMATIC bacteria: -Treat only in pregnancy to prevent pyelonephritis Why? Pyelonephritis incidence is increased in the third trimester (may precipitate preeclampsia, sepsis and miscarriage) -Sterile pyuria: -Genitourinary TB (classic sterile pyuria) -Chlamydia (most common) -Acute urethral syndrome: -Sterile or low bacterial count with dysuria DDX: -Chlamydia -GC -HSV -Vaginitis TX: Empiric Rx of STDs in men.

What are indications for transcutaneous pacing?

-AV block (Mobitz Type II or complete heart block) -Sinus node dysfunction -Torsade de pointes.

What is Third degree AV block (complete heart block), and what is prognosis?

-AV dissociation: no relation between P and QRS → PR interval changes randomly Think narrow vs wide for prognosis. -Junctional (narrow QRS's good prognosis) or -Ventricular (wide QRS's bad prognosis) escape beat - Assoc. with anterior MI and destruction of conduction tissue -Narrow complex: may be temporary due to vagal tone -Wide complex: usually requires transvenous pacer

What are the 3 different dysrhythmias that complicate WPW syndrome & how do they differ in management?

-AVRT (atrioventricular reentrant tachycardia) #1 & #2 1) narrow (orthodromic) -AVRT 2)wide (antidromic) QRS complex -AVRT 3) A. fib TX: -Easy one = Orthodromic AVRT: AV node blocking agents, such as adenosine, calcium channel blockers, and beta-adrenergic antagonists. -Dangerous: Other 2 rhythms Wide (antidromic) & A.Fib with WPW -Much more malignant -TX: IV procainamide and/or electrical cardioversion.

An HIV patient starts a NRTI and by week 4 starts having fever, rash, n/v/d, and malaise. What is diagnosis and treatment?

-Abacavir reaction= 4% = fever, skin rash, N/V, diarrhea, abdominal pain, malaise, lethargy -A Hypersensitivity reaction -First six weeks -Stop the drug -Symptomatic treatment

What are the contraindications to use of noninvasive ventilation (NIV)?

-Absent or agonal respiratory effort -Altered level of consciousness -Maxillofacial trauma -Basilar skull fracture -Epistaxis -Vomiting -Hypotension

What is profile of patient with acalculous cholecystitis, and what is the morbidity compared with calculous cholecystitis?

-Acalculous cholecystitis = No stones Usually a complication of another process (trauma, burn, postpartum, post-op, narcotics) -Patients often critically ill -Can cause GB perforation ***Increased risk with diabetics and elderly Greater morbidity than calculous cholecystitis

What is difference between mechanism of toxicity between organophosphate and carbamate poisoining?

-Acetylcholinesterase-organophosphorus compound is irreversibly bound. -Carbamate compounds are transient cholinesterase inhibitors, spontaneously hydrolyzing from cholinesterase within 48 hours.

What does aPTT stand for, and what does it measure? What prolongs aPTT?

-Activated partial thromboplastin time -Measures INTRINSIC system and common pathway -Prolonged aPTT -Heparin -Hemophilia -von Willebrand's disease -Lupus anticoagulant

At what temperature must you start internal rewarming techniques?

-Active core rewarming: Core temp < 30 ˚C or cardiac instability evident -Warm humidified O2 -Warmed IV fluids -Gastric, bladder, chest or peritoneal lavage with warm NS -Dialysis, extracorporeal bypass rewarming The patient is not dead until warm and dead (core temp > 30 ˚C) is false... -Potassium > 10-12 mEq/L means patient is TRULY dead: High K+ from cell breakdown

What are the differences between Acute infective endocarditis & Subacute infective endocarditis?

-Acute IE: -Young, normal valves -Higher morbidity and mortality -Staph. aureus -Subacute IE: -Old, abnormal valves -Anemia of chronic disease -Strep. viridans (50-60%)

In elderly with abd pain on board exams think 3 things.

-Acute MI -Ruptured AAA or -Mesenteric ischemia

What are 5 Differential diagnoses of diffuse ST elevation?

-Acute MI (large one!) -Prinzmetal's angina (vasospasm) -Pericarditis -Ventricular wall aneurysm -Benign early repolarization

A traveler drove up to altitude of 10,000 feet to a campground. He had a beer and then later began to have a headache and nausea, and insomnia. What is the diagnosis and treatment? How could he have prevented this?

-Acute Mountain Sickness -Common with rapid ascent to 8-10,000 feet -Headache, nausea, fatigue, insomnia +/- GI sx -Worse with drugs, alcohol, sedatives, and any respiratory depressant -Tx: Steroids, oxygen, descent -Prophylaxis: Acetazolamide (carbonic anhydrase inhibitor) Renal bicarbonate diuresis and metabolic acidosis -Increases respiratory drive -Increases oxygenation since less sleep-related hypoventilation -Avoid in sulfa allergy Can cause paresthesias

Patient presents with migratory polyarthralgia, signs of carditis and pericarditis, and fever with recent streptococcal infection. What is the diagnosis?

-Acute Rheumatic Fever

What is leading cause of intrinsic renal failure? What are the 2 main categories of etiologies for this sort of renal failure? What are the 2 main causes in each of the 2 main categories causing ATN?

-Acute Tubular Necrosis (ATN) 1) ISCHEMIA (from prerenal) -Oliguric (<500 mL/day) -Leading causes: trauma and sepsis 2) TOXIC-POISON -Not oliguric Causes: -Contrast media -Myoglobin(rhabdomyolysis) -Hemoglobin (hemolysis) -Aminoglycosides -Multiple myeloma -Ethylene glycol

What 2 diagnoses do you consider in patient with acute painful eye and vision loss?

-Acute angle-closure glaucoma -Optic neuritis

What is the leading cause of sickler death and 2nd most common cause of hospitalization in ticklers? How does it present?

-Acute chest syndrome -Most cases < 21 y/o Clinical syndrome: -New pulmonary infiltrate involving at least one complete lung segment (usually lower lobes) -Chest pain -Fever > 38.5C -Tachypnea, wheezing or cough

What is onset and duration of panic attacks?

-Acute in onset and peak within a few minutes to an hour.

What is the most common type of pediatric leukemia?

-Acute lymphoblastic leukemia

How does delirium present?

-Acute onset of confusion and inattention and associated with mood lability and agitation.

What conditioned is defined by: -Pao2/Fio2 < 300 (PaO2 <60 mmHG & FiO2 >0.5) -Bilateral pulmonary infiltrates with normal heart size on chest X-ray -Elevated pulmonary artery pressure < 18 mm Hg.

-Acute respiratory distress syndrome Actually this is old definition but for board exam still use these definitions.

Patient presents with: -JVD -Peripheral edema -Right upper quadrant pain What is the diagnosis and what are the causes?

-Acute right sided failure (uncommon) Signs and symptoms -JVD early -Peripheral edema -RUQ pain (liver engorgement) -Pulsatile, enlarged liver Causes: -Left sided failure (Most common cause) -Pulmonary embolism -RV infarction

Hepatorenal syndrome is marked by ________ and ________.

-Acute serum creatinine elevations and oliguria.

What is #1 cause of SBO?

-Adhesions (#1 cause) -Hernias -Malignancy -X-ray: "step ladder," "string of pearls;" plicae circulares (traverse bowel width)

In the setting of intentional overdose of a large amount of a strongly caustic agent, the appropriate recommendation is what?

-Admission monitoring and serial examinations GI bleeding or perforation\ -Endoscopy to grade the extent of the injury.

If have sulfonylurea overdose always __________.

-Admit

How do you treat a patient with third-degree heart block who is lightheaded, having chest tightness, or has syncope?

-Admit to a monitored bed.

Can Nurse practitioners and PA's practice independently, and what is their scope of practice?

-Advanced practice RNs may practice independently in some states. -Physician assistants practice under the supervision of a physician. -Advanced practice provider scope of practice and supervision vary by state and by individual emergency department.

What is Type I Decompression Sickness, and what is most common form?

-Affects musculoskeletal, skin, lymphatics "The Bends" or "Caisson's Disease" named after workers in caisson on Brooklyn bridge died/suffered from decompression sickness type I. -Periarticular pain (especially elbows and shoulders) -Pruritus, erythema, skin marbling ("cutis marmorata") from venous stasis

What is the criteria for "wait and see" for prescription for an antibiotic if symptoms do not improve in 48 to 72 hours in acute otitis media?

-Age ≥ to 2 years old -Unilateral infection -Symptoms < 48 hours -Temperature < 39⁰C.

At what point is Smallpox (variola virus) contagious, and what is unique about the skin lesions?

-Airborne transmission, highly infectious -Not contagious until rash appears -Incubation 1-2 weeks -All lesions OCCURR AT SAME TIME. -Vaccine: Live virus (vaccinia). Primary protection fades after 5 years, revaccination lasts 30+ years -Post-exposure vaccine is effective up to 3 days

What is most common cause of hepatits?

-Alcoholic hepatitis

What are the 5 contraindications to nasogastric aspiration?

-Alkali injury/corrosive ingestion -Basilar skull fracture or midface injury -Coagulopathy -Esophageal strictures -Gastric bypass or lap band surgery

What are the ABA Admission Criteria?

-All 2˚ burns >10% BSA -All 3˚ burns (unless extremely small) -All inhalation injuries -Seared nasal hairs -Sooty mouth -Enclosed space -All burns to face, ears, eyes, hands, feet, genitalia, perineum, major joints, Flexor creases -Electrical burns -Circumferential burns -Co-morbid diseases likely to worsen progression -Children <12 months of age

Total Anomalous Pulmonary Venous Return TAPVR

-All 4 pulmonary veins are malpositioned. (Should drain freshly oxygenated blood into left atrium and then to rest of body, so blood simply circles to and from lungs) - For infant to live there must be atrial septal defect or patent foramen ovale -Cyanotic congenital cardiac disease -Decreased pulse ox

What are the 3 Factor Xa Inhibitors?

-All are oral meds. -Rivaroxaban (Xarelto) -Apixaban (Eliquis) -Edoxaban (Lixiana) -All are excreted renally. -FACTOR Xa is a component of the FINAL COMMON PATHWAY of the clotting cascade -SO aPTT & INR tests cannot be used.

Where are anal fissures most often found?

-Along the posterior midline.

How do you treat HTN from Pheochromocytoma, MAOI crisis, cocaine overdose (Catecholamine crisis )?

-Alpha blocker plus beta blocker is best -Do not use beta blocker alone!!! (avoid unopposed alpha effect) -Labetalol plus phentolamine (alpha blocker)

What is most sensitive for the diagnosis of carpal tunnel syndrome?

-Alteration in sensation to the distal tuft of the index finger.

What is most common cause of dementia in patients > age 65?

-Alzheimers Dementia

How do you identify a local anesthetic as an aside?

-AmIde local anesthetic agents contain two "i's" in their names: Bupivacaine Lidocaine Ropivacaine Levofupivacaine Mepivacaine Prilocaine

Delayed-onset (after 6 hours) vomiting and diarrhea are characteristic of poisoning from ______________________.

-Amanita species and are associated with hepatic failure & death. -Mushroom toxicity with early vomiting and diarrhea (< 6 hours) generally portends a favorable outcome and less toxic ingestion.

Iodoquinol is used for treatment of _____________________.

-Amebic dysentery from Entamoeba species -Blood-streaked mucous diarrhea, Colonic ulcerations

In patient with fever and bronchiolitis why do you check UA?

-American Academy of Pediatrics defines bronchiolitis: -Child younger than 24 months. -Rhinitis -Tachypnea -Wheezing -Cough -Crackles -Accessory muscle use -Nasal flaring -3% chance of a concomitant urinary tract infection in infants with respiratory syncytial virus bronchiolitis. -Fever is common with bronchiolitis, but consider urinary tract infection.

What are 1st line antiarrhythmic agents for stable VT?

-Amiodarone -Procainamide. 2nd line agents: -Sotalol -Lidocaine

What should you give a patient with acute STEMI who is waiting for PCI?

-Aspirin -Pain control -Antiplatelet therapy (Clopidogrel, ticagrelor or Prasugrel) -Anticoagulation - IV heparin

A full term woman has a successful delivery all of sudden has cardiovascular collapse, seizures, and goes into shock? What is dx?

-Amniotic Fluid Embolism -2nd and 3rd trimesters -Release of amniotic fluid into maternal circulation resulting in an immunologic maternal response, simulating anaphylaxis -Rare -Occurs with labor, C-section, abruptio placentae, abortion, amniocentesis, trauma -Sudden cardiovascular collapse, usually SOON AFTER DELIVERY, seizures -Shock, dyspnea, hypoxemia, ARDS, DIC -High mortality (50% at one hour); supportive care

What is initial antibiotic choice for bacterial tracheitis?

-Ampicillin-sulbactam or 3rd generation cephalosporin + Vanco or clindamycin

What is Goodpasture syndrome in children, and how does it present?

-An autoimmune disease that attacks collagen in alveoli and glomeruli. -Older children -Presents with the syndrome of glomerulonephritis and pulmonary hemorrhage, but may present with glomerulonephritis alone. -SOB -Cough -Hemoptysis -Pulmonary infiltrates on chest x-ray -Sudden onset of hematuria (either gross or microscopic) with proteinuria -HTN blood -Edema.

What is priapism, and what is the most likely complication of untreated priapism? What anatomical parts are involved in priapism vs a normal penile erection?

-An erection lasting longer than 2 hours -Most common side effect is impotence.

What is malignant hyperthermia, and what is the treatment?

-An inherited condition where there is inappropriate release of calcium from the sarcoplasmic reticulum in skeletal muscle in response to medications such as succinylcholine and certain inhaled anesthetics. -Treatment: -Immediate administration of dantrolene, an agent that antagonizes the excessive release of calcium from the sarcoplasmic reticulum. -Supportive care with cooling and hydration

What should emergency physician think of jaundice in the first 24 hours of life of a newborn?

-An ominous finding! -Neonatal Jaundice in newborn younger than 24 hours: -Hemolytic disease of newborn: -ABO, Rh, minor blood group incompatibility -Infections: -TORCH infections :●Toxoplasmosis ●Other (syphilis) ●Rubella ●Cytomegalovirus (CMV) ●Herpes simplex virus (HSV) -malaria -G-6PD deficiency

Only large retinal detachments are seen on direct ophthalmoscopic examination as pale areas. To visualize smaller detachments, a dilated indirect and direct retinal examination must be done by _________________.

-An ophthalmologist. ***Cannot be ruled out by direct funduscopy. Ultrasound helpful in dx.

What is Guyon Canal syndrome (aka handlebar palsy)?

-An ulnar mononeuropathy rather than a median neuropathy as with carpal tunnel syndrome -Compression of ulnar nerve at the wrist causes weakness of intrinsic muscles of the hand

What is most common cause of painful rectal bleeding in adults and children?

-Anal Fissure -Occurs in midline, posterior area. -if NON-MIDLINE fissures present then it suggests more serious conditions (IBD, CA, sexual abuse) know this Tx: Perianal hygiene, WASH regimen, NTG, topical nifedipine ointment, WASH: Warm sitz bath Analgesia Stool softener High fiber diet

What are the most common cause of painful rectal bleeding and can be exquisitely painful?

-Anal fissures

What are the most common cause of acute-onset severe rectal pain and can involve rectal bleeding?

-Anal fissures -Anal fissures usually occur in patients who are constipated and have passage of hard feces.

What is a delayed hemolytic reaction after transfusion?

-Antigen-antibody reaction after 7-10 days

What is most common personality disorder seen in ED?

-Antisocial Personality -Severity decreases after age 30 -Common complications: Substance abuse, multiple divorces, trauma, poor medical compliance -Disrespect for rights of others, law

What is clinical presentation of spontaneous bacterial peritonitis (SBP)?

-Any patient with ascites with: -Fever -Chills -Malaise -Abdominal pain -Confusion -Hypotension -General clinical decline.

Why is isoproterenol contraindicated in Tet spell?

-Anything that decreases pulmonary blood flow or decreases SVR is harmful. -Isoproterenol increases heart rate and contractility increasing right to left shunting & vasodilates of peripheral vasculature (decreases SVR)

The differential diagnosis of new-onset flank pain in men older than 60 years must include _____________.

-Aortic aneurysm because first-time kidney stone is unlikely.

History of abdominal aortic aneurysm or prior surgical repair of an aneurysm + GI bleeding should make you look for ______________.

-Aortoenteric fistula. The mortality rate is high. -Surgery is the definitive treatment for aortoenteric fistula.

How do bilateral facet dislocations appear on plain film x-rays, and are they stable or unstable?

-Appear as vertebral subluxations and should be obvious. -Inherently unstable and associated with neurologic deficits.

What is the most common non-OB surgical emergency in pregnancy?

-Appendicitis

What is most common surgical emergency in pregnancy? What is a common misdiagnosis for this surgical emergency in pregnancy?

-Appendicitis -Diagnosis: Ultrasound helpful; CT scan; MRI becoming more accepted -Pyelonephritis is a common misdiagnosis in missed appendicitis in pregnancy

What is Pulmonary Embolism Ruleout Criteria (PERC Rule)?

-Applied to patients at low risk for PE based on clinical impression: 8 criteria: -Age < 50 years -No exogenous hormone use -Oxygen saturation > 94% RA -Pulse < 100 beats per minute -No hemoptysis -No unilateral leg swelling -No prior history of PE or DVT. -No recent major surgery

A diver surfaces rapidly because he saw a shark down below. Ten minutes later he has a seizure and has an altered mental status. What is diagnosis and the needed treatment?

-Arterial gas embolism or AGE (high morbidity and mortality) Pulmonary overpressurization causes alveolar gas to enter systemic circulation -Air emboli in coronary, cerebral and retinal arteries -Sudden and dramatic symptoms often with focal neuro findings Presents on surfacing or within 10 minutes Unlike decompression sickness, which occurs gradually -ALOC is the rule and seizures are common -TX: Dive chamber "stat"

Patient with AICD present for single discharge vs multiple discharges, what do you do?

-Assess for concerns of ACS or arrhythmia based on history and exam -Check lytes -If no concerns identified, patients can be discharged to close followup 1-shock = CAN GO HOME IF ALL NORMAL For multiple discharges MANDATES INTERROGATION -If continuing discharges, use magnet to inactivate AICD -Cardiac arrest: no change in protocols is needed Place your own pads (A-P), 8-10 cm away from AICD

Why should NSAIDS be avoided in patients with acute MI?

-Associated with increased adverse cardiovascular events.

What concerns do you have with Anal fissures located laterally?

-Associated with systemic disease such as: -HIV -TB -Crohn disease

What are contraindications to beta blockers?

-Asthma -CHF -Bradycardia -Hypotension -Caution in RV MI

What are SCUBA Diving contraindications?

-Asthma -COPD -Seizures -Sinus and ear disease or runny nose Syncope Panic disorder Vertigo Poor training

What are key etiologies of pneumomediastinum?

-Asthma -Environmental factors such as diving or flying -Thoracic trauma -Forceful retching

How does High Altitude Cerebral Edema present and what is treatment?

-Ataxia, vomiting, confusion, seizures, coma TX - NO O2. Just DESCEN!T Descent (definitive treatment) -Steroids, mannitol -Hyperbaric chamber (Gamow bag)

Eczema is AKA __________. What is the profile of this patient?

-Atopic Dermatitis -Assoc. with asthma and allergic rhinitis -Erythema, crusts, fissures, pruritis, excoriations, lichenification -Chronic pruritic skin condition -Infants: Blisters, crusts, exfoliation (face, scalp, extremities),1st few months. Resolves by age 2 Adults: Dryness and thickening in antecubital and popliteal fossae, neck -Worse in winter -Treatment: corticosteroids, antipruritics

Unstable Tachyarrhythmias and management: Atrial fibrillation—Synchronized cardioversion _________ J Atrial flutter—Synchronized cardioversion _____J Pulseless ventricular tachycardia and ventricular fibrillation—Defibrillation ________J followed by _______ J Stable ventricular tachycardia—Synchronized cardioversion ____ J Supraventricular tachycardia—Synchronized cardioversion ____ J

-Atrial fibrillation—Synchronized cardioversion 100-200 J Atrial flutter—Synchronized cardioversion 50 J Pulseless ventricular tachycardia and ventricular fibrillation—Defibrillation 120 J followed by 200 J Stable ventricular tachycardia—Synchronized cardioversion 50 J Supraventricular tachycardia—Synchronized cardioversion 50 J

What are critical steps in the initial management of poisonings from organophosphorus compounds?

-Atropine and aggressive airway management

-Attention deficit hyperactivity disorder (ADHD) Inappropriate degree of ______________. Treatment: ? -Tourette syndrome: ? -Night terrors: ? -Pica: ?

-Attention deficit hyperactivity disorder (ADHD) Inappropriate degree of gross motor activity TX: methylphenidate, Dexedrine -Tourette syndrome: Motor and vocal tics -Night terrors: Last 15 minutes Screams Incoherent speech Amnesia -Pica: Ingestion of non-nutritional substances

Patients who have pneumonia from ____________ pathogens complain of a dry, nonproductive cough.

-Atypical -Atypical pneumonias: -Legionella pneumophila -C. pneumonia -Mycoplasma pneumoniae,

What are the most common infections found in sickle cell patients with acute chest syndrome?

-Atypical bacteria M. pneumonia -Chlamydia pneumoniae.

What is Brigade syndrome?

-Autosomal dominant genetic disorder abnormal EKG -Pseudo-RBBB pattern -ST elevations in V1 and V2 -Common in SE Asian males -Has Syncope or sudden death in young patients with a structurally normal heart resulting from polymorphic VT → ventricular fibrillation -Tx: Implantable defibrillator

What structures must you avoid when placing sutures or staples to repair wound in heart when doing thoracotomy?

-Avoid the coronary arteries

What nerve do you need to avoid when performing thoracotomy, and how do you do avoid it?

-Avoid the phrenic nerve by cutting more anterior when incising the pericardium.

What medications do you avoid in patients with possible mesenteric ischemia?

-Avoid: -Digoxin -Beta blockers -Vasopressors (decrease splanchnic blood flow)

Cryptosporidium or bacterial Salmonella species causing diarrhea is treated with ________________?

-Azithromycin

What is the PECARN RULE: Findings associated with very low risk of significant traumatic brain injury in children >=2 to 18 years old?

-BASiLAR mnemonic = -Basilar skull fracture signs -AMS -Severe mechanism of injury -LOC -Ache of head -Regurgitation (vomiting) -Normal mental status◊ -No LOC -No severe mechanism of injury§ -No vomiting -No severe headache -No signs of basilar skull fracture¥ -Severe mechanism same as for <2 y/o except: ->1.5 m (5 feet) considered severe. -Head struck by high impact object -Motor vehicle collision with patient ejection, death of another passenger, or rollover; -Pedestrian or bicyclist without helmet struck by a motorized vehicle.

In advanced liver disease are these patients are at risk for bleeding or thrombosis?

-BOTH! -PT and INR increase -Protein C and antithrombin III activity decrease -So these patients are at risk for both bleeding and DVT.

How is angioedema different from urticaria?

-BRADYKININ-mediated, NOT allergic rxn so not IGE mediated ↑ Vasodilation ↑ Vascular permeability -So does not respond to epinephrine, antihistamines, or glucocorticoids. -DEEP dermis edema as opposed to Hives in superficial dermis -Common cause: ACE inhibitors

What is the most common presenting symptom in spinal epidural abscess?

-Back pain

What are the direct thrombin inhibitors, and which one is the only oral direct thrombin inhibitors?

-Bivalirudin IV(Angiomax, previously called Hirulog) -Argatroban IV ((Arganova, Aragon, Argatra, Novastan) -Desirudin SQ (Iprivask, Revasc) -Oral direct thrombin inhibitor — DABIGATRAN (PRADAXA) is the ONLY ORAL DIRECT THROMBIN INHIBITOR available for clinical use.

What is the genus name for Black Widow & Brown Recluse spiders?

-Black Widow = Lactrodectus (Black & Lact rhyme) -Brown Recluse = Loxoscelese

What is the most common cause of vaginal discharge? What are the 3 criteria you need to do dx? What is tx? How should asymptomatic women be treated?

-Bacterial Vaginosis -Organism: Gardnerella and anaerobes -CDC recommends Amsel's diagnostic criteria (3 of 4 listed below), or gram stain -Copious thin white homogenous discharge -Clue cells (vaginal epithelial cells with adherent bacteria) on wet prep -pH > 4.5 -Fishy odor with potassium hydroxide (KOH) whiff test TX: Metronidazole 500 mg PO bid (7 days) ***All pregnant patients should be treated Risk of preterm labor, PROM, preterm birth, postpartum endometritis ***All symptomatic women need treatment ***Do not treat asymptomatic, nonpregnant women

What is the most common comorbid complication of bronchiolitis?

-Bacterial otitis media (60%)

What diagnosis should be suspected in children who present with acute onset of airway obstruction in the setting of viral upper respiratory infection and in children who are febrile, toxic-appearing, and have a poor response to treatment with nebulized epinephrine or corticosteroids?

-Bacterial tracheitis

What disease do you suspect in patients between 5-8 y/o who have high fever and are toxic with airway symptoms following a viral URI?

-Bacterial tracheitis -Other names: -Membranous laryngotracheobronchitis -Pseudomembranous croup -Bacterial croup. -Occurs in previously healthy children in the setting of a viral respiratory tract infection. -Common clinical features include: -Fever -Stridor -Cough -Respiratory distress.

What is balanoposthitis, and what must you r/o if this appears? How do you tx it?

-Balanitis: glans penis -Posthitis: foreskin -R/o diabetes -TX: -soap and water, keep dry -Bacitracin (peds) -Topical clotrimazole (adults)

What is treatment for Sting Ray stings?

-Barbed stinger apparatus Laceration, then envenomation -Sx's: include local injury, nausea, flushing, diarrhea, diaphoresis, cramps, intense pain -Tx: Clean wound with water flush Debride Soak in water AS HOT AS TOLERATED (treats pain by deactivating toxin which is heat sensitive) Antibiotics (+/-) -X-Ray for retained foreign body;

What is most common skin malignancy?

-Basal Cell Carcinoma -Pearly, rolled up pizza dough border with central ulceration -Not a metastasizing tumor -Head and neck -Seen only where hair follicles exist -Cure rate 100% if found early

What are high-risk animals for rabies in the United States?

-Bats -Foxes -Raccoons -Skunks.

If patient's symptoms of testicular torsion have already been present for 12 hours, what should the emergency physician do?

-Because this patient's symptoms have already been present for 12 hours, the emergency physician should attempt detorsion of the testis and obtain emergent urologic consultation.

How do you treat toddler fractures?

-Benign, so you can treat them conservatively in the emergency department with a long-leg splint. -Very common injury in children who have recently began to walk (toddlers).

What drugs can cause methemoglobinemia?

-Benzocaine -Chloroquine -Dapsone -Phenazopyridine -Prilocaine -Primaquine

What is first-line therapy for the management of excited delirium syndrome, especially if the source of agitation is thought to be stimulant drug use?

-Benzodiazepines

What medication do you give for alcohol withdrawal sz and which one do you not give?

-Benzodiazepines for alcohol withdrawal seizures not phenytoin (Dilantin)

Why is elliptical incision used to excise an acute thrombosed external hemorrhoid, and what are the 5 contraindications?

-Best to evacuate a thrombosed hemorrhoid and minimize complications without the need for sutures post procedure -Linear incision is associated with a significant rate of rethrombosis. -Contraindications: -Immunocompromised -Pregnant -Portal hypertension -Coagulopathy -Pediatric patient.

What is treatment for aortic dissection?

-Beta blockers, then nitroprusside for both types -Stanford A: requires surgery -Stanford B: 1/3 will require surgery for complics.

What are the mainstay of therapy for Hypertrophic cardiomyopathy?

-Beta-blockers: -Decreases the effect of catecholamines on the outflow gradient.

What 2 types of medications may you use to treat aortic dissection?

-Beta-blocking agents are the mainstay of medical therapy for aortic dissection. -Nitrates also can be used to reduce blood pressure in patients with aortic dissection and STEMI. -Nitrates can cause reflex tachycardia & so use with a beta-blocker. -Nitroprusside is the nitrate of choice in dissection because it is a more effective arterial dilator than nitroglycerin.

What is biggest risk factor for development of Alzheimer disease & how do they present?

-Biggest risk factor for development of Alzheimer disease is age. -Age of onset is the eighth or ninth decade of life. -Can be seen earlier in patients with strong genetic predisposition -Present with memory loss and decline in executive functioning. -Aphasia (language disturbance) -Apraxia (impaired motor ability) -Agnosia (difficulty recognizing objects)

What changes are seen in brain with PRES (posterior reversible encephalopathy syndrome), and what is the imaging study of choice?

-Bilateral white matter changes in the posterior temporal and occipital lobes -MRI.

What are the 3 most common causes of unconjugated hyperbilirubinemia (indirect bilirubinemia)?

-Bilirubin overproduction (Hemolysis) -Gilbert syndrome -Neonatal jaundice. UNCONJUGATED HYPERBILIRUBINEMIA occurs from 3 mechanisms: 1) Overproduction of bilirubin 2) Reduced bilirubin uptake 3) Impaired bilirubin conjugation

What is profile of patient affected by aortic dissection?

-Bimodal age distribution -Young with predisposing factors -Collagen vascular disorders such as Marfan's -Pregnancy (especially third trimester) -Chest trauma, iatrogenic (cardiac catheterization) Bicuspid aortic valve Aortic coarctation -Elderly males with chronic hypertension

Patient presents with mood changes, "flight of ideas," hyperactivity, and has rapid, pressured speech, grandiose behavior. -Has inability to sleep, concentrate or control impulses -Flamboyant dressed with inappropriate behavior. What is dx?

-Bipolar Disorder TX: Lithium

What is the pathogen of Lyme Disease, and how do the 3 stages present?

-Borrelia burgdorferi (spirochete) Transmitted by Ixodes ticks Tick reservoirs: Rodents, rabbits, deer -Fever, myalgias, arthralgias, headache -3 stages 1) Localized (rash) 2) Disseminated (neurologic and cardiac) 3) Persistent (arthritis)

What is difference between cellulitis and erysipelas?

-Both are skin and soft tissue infections. -Cellulitis involves the deeper dermis and subcutaneous fat -Cellulitis may present with or without purulence; erysipelas is nonpurulent -Cellulitis -middle-aged individuals and older adults. -Erysipelas involves the upper dermis and superficial lymphatics. -Erysipelas in young children and older adults

What is difference between petechiae and purpura?

-Both deposits of blood under skin -Petechiae/Purpura = Non-blanching (Blanching = vasodilation) -Petechiae <3 mm, purpura >3 mm -Non-palpable: Platelet disorder, thrombocytopenia -Palpable purpura = Vasculitis Tx: Antibiotics, steroids, plasmapheresis (depends on etiology)

What poisoning has similar clinical manifestations of tetanus?

-Both strychnine poisoning and tetanus are characterized by recurrent, episodic, involuntary muscular contractions. -Muscular contractions can appear to be convulsions in strychnine poisoning, BUT the sensorium is unaffected.

Which jellyfish is the deadliest one?

-Box jellyfish deadliest (respiratory arrest)

What signs can you expect to see in patients with myxedema coma?

-Bradycardia -Decreased ventilation -Hypotension -Severe hypothermia -Can have NONPITTING facial and pretibial edema -Myxedema coma is the most extreme form of hypothyroidism, so has signs and symptoms of decreased metabolic rate.

What is the Mammalian diving reflex (sudden cold water immersion)?

-Bradycardia, apnea -Shunting of blood to CNS -Children > adults

In children, _______________ can show up suddenly as a neck mass and prompt a visit to the emergency department.

-Branchial cleft cysts -Most children who present with these neck masses are <5 y/o, and the masses can occur spontaneously.

What is the most common form of plague?

-Bubonic plague - not contagious. -Infected flea bites a person, or materials contaminated with Y. pestis enter through a break in the skin -Swollen, tender lymph nodes (buboes) -Fever, headache, chills. No spread from person to person

What medication is contraindicated in patients with eating disorders?

-Bupropion - Lowers seizure threshold in those with electrolyte abnormalities and can also lead to worsening weight loss.

In addition to burns of the face or perioral region, what are other indications for rapid intubation in setting of burn patient?

-Burns of the face or perioral region, -Acute respiratory distress -Worsening hoarseness -Stridor -Altered mental status with respiratory depression -Circumferential neck burns -Supraglottic edema as seen by fiber optic examination

If button battery is seen in esophagus, then what must be done and why?

-Button batteries = high risk GI emergency If seen in esophagus, must be REMOVED IMMEDIATELY -Rapid burns with PERFORATION in 6 hours -Lithium batteries have the worst outcomes

What is mnemonic for recalling the substances that charcoal does not bind?

-C-PHAILS: -Caustics -Pesticides -Hydrocarbons -Alcohols -Iron -Lithium -Solvents

What is cause of pseudomembranous enterocolitis, and how do you treat it?

-C. difficile -Begins 1 week after antibiotics TX: Stop the precipitating antibiotics; Oral Metronidazole or Vancomycin -No anti-diarrheals

Male presents with tender and painful ulcer of penis and also has painful inguinal adenopathy. What is organism and diagnosis? How do you TX?

-CHANCROID -Haemophilus ducreyi Rare in U.S. -Primary infection Ulcers + adenopathy Tender papule followed by painful ulcer (multiple lesions may be present and coalesce) -Painful inguinal adenopathy (buboes) Culture! -TX: azithromycin or ceftriaxone (single dose treatment with either agent)

What is clinical presentation of dilated cardiomyopathy?

-CHF (biventricular failure) -Dysrhythmias -Sudden death CXR: Globular heart &/or CHF

How is rhabdomyolysis diagnosedby laboratory analysis?

-CK level at least 5 X's the normal level -Presence of urine myoglobin

What 4 other crises, outside of acute chest syndrome, can Sickle Cell Vasoocclusive Crisis occur?

-CNS crisis: painless, cerebral infarction in children / hemorrhage in adults Other CNS problems: TIAs, strokes, seizures, paresthesias -RENAL crisis: infarction, hematuria, flank pain, papillary necrosis -HAND-FOOT Syndrome: in first two years of age, swelling of hands or feet due to avascular necrosis due to vasoocclusion - may be first sign of sickle cell disease -PRIAPISM - exchange transfusion / corpus cavernosum (lateral corpora) epi and aspiration

What is the primary diagnostic study for acute mesenteric ischemia in the emergency department?

-CT angiography

How are carotid and vertebral dissections diagnosed and treated?

-CT angiography or MR angiography -Tx with heparin followed by warfarin.

What is the test of choice for diagnosis of aortic dissection?

-CT chest angiography

Preseptal and postseptal orbital cellulitis have overlapping clinical symptoms, so what is the definitive diagnostic test to distinguish between the two?

-CT or MRI of the orbits.

When does sensitivity of CT scan decrease with respect to onset of headache from SAH? What are the 2 findings on LP if patient has SAH? What medication do you give to control HTN for SAH?

-CT scan sensitivity decreases after 12 hours LP findings for SAH Xanthochromia (takes 6 - 12 hours to develop) Non-clearing RBCs (e.g. from tubes 1-4) TX: Aggressive blood pressure control, nimodipine PO/NG (to prevent vasospasm), -neurosurgical consult, -Do CT angio if LP has blood

What is imaging study of choice for aortic dissection?

-CT with contrast is first-line test -TEE (transesophageal echo) Very sensitive and specific → BEST test if available -Test of choice

What occurs with aerosolized botulism?

-Can be absorbed through inhalation. -Binds to the preganglionic membrane of cholinergic synapses and inhibits acetylcholine release -Earliest complication involves the eyes (double vision). --------------> descending paralysis and respiratory failure Unlike nerve agents, doesn't cause miosis or copious respiratory secretions

What is the problem with mantoux or tuberculin skin testing?

-Can be false positive if a patient has had a BCG (bacille Calmette-Guerin) immunization. =Can be falsel negative if the patient has an immunosuppressive disorder (including HIV), steroid therapy, or chronic illness.

What is value of serum uric acid acute grout attack?

-Can be high or normal, so should not be used to confirm the diagnosis of gout.

Why is pacing in patients with severe hypothermia contraindicated?

-Can induce ventricular fibrillation.

What is acrocyanosis?

-Can persist for 24 to 48 hours and is not a sign of hypoxia, but is rather related to blood flow and vasoconstriction. -Often seen in healthy newborns and refers to the peripheral cyanosis around the mouth and the extremities (hands and feet

What is #1 cause of large bowel obstruction?

-Cancer (#1 cause) -Volvulus -Diverticulitis -Obstructive series: distended colon, haustral pattern (doesn't traverse entire bowel width) -CT scan if diverticular etiology or intussusception -Closed loop obstruction: a specific type of obstruction in which two points along the course of a bowel are obstructed at a single location thus forming a closed loop. -Due to adhesions, a twist of the mesentery or internal herniation. -In the large bowel it is known as a volvulus.

Therapeutic Hypothermia (Targeted Temperature management)

-Candidates: -Shockable rhythm -Resuscitated out of hospital -Stable and non responsive (Alert, unstable, non-cardiogenic cardiac arrest not a candidate) -Initiate first 4-6 hours after resuscitation, early 15-30 mins after resuscitation is appropriate. -Target temp: 32-34 degrees Celsius -Additional post resuscitation like PCI should be performed simultaneously.

What is Carcinoid Syndrome, and how does it present?

-Carcinoid tumor: Circumscribed GI tumors occurring in small intestine, appendix, stomach, colon -Secretes serotonin, prostaglandins and other substances -Get: -Skin flushing -Vasodilation -Hypotension -Watery stools, -Edema -Bronchoconstriction -Ascites Attacks can last from minutes to days

What is the most appropriate diagnostic-treatment approach to Wellens syndrome, and what should you avoid?

-Cardiac catheterization with subsequent PCI -Avod provocative testing in the evaluation of Wellens Syndrome

What is most sensitive test for placental abruption?

-Cardiotocodynamometry, which identifies irritability of the uterus, most notably uterine contractions.

What is the most sensitive modality for identifying occult injury to the uterus or to the fetus?

-Cardiotocographic monitoring -Monitor 4 to 6 hours after even the most minor trauma, either blunt or penetrating. -Can identify subtle changes in fetal heart rate that might indicate fetal distress. -Can identify uterine irritability or early signs of placental abruption.

What are requirements to bill for critical care services?

-Cared for a patient with a critical illness or injury that impairs one or more vital organ systems such that a high probability of deterioration is present. -Spent at least 30 minutes on care - Cannot include time spent on separately billable procedures -can be STABLE and still qualify for critical care time if they have critical illnesses or injuries and have the potential to deteriorate. -no specific requirement for vasopressors, invasive monitoring, airway management, or other specific interventions.

Patient presents with rigidity, mutism, grimacing, stupor. What is dx, and what dx must you r/o?

-Catatonia -Rule out neuroleptic malignant syndrome, NMS patients are very sick

What is the cause of weakness in atrial fibrillation with rapid ventricular response?

-Cause of weakness in AF is the reduced time for ventricular filling resulting in decreased systemic perfusion.

What is angioedema from ACE inhibitors caused by?

-Caused by decreased metabolism of bradykinin -Leads to vasodilation and vascular permeability -Leads to edema of deep dermis -NOT IgE mediated so the tx for allergic run/urticaria like antihistamines, steroids, and epi doesn't work.

What is profile of Infant botulism?

-Caused by ingestion of Clostridium botulinum. -Associated with ingestion of honey or corn syrup. -More common in breastfed infants, as breast milk affects gastric acid or bile acids that normally minimizes Clostridium growth -C. botulinum can also be ingested on a fomite when local construction has caused it to be mobilized from the soil. -Mortality rate: 5%-10%

Central Vertigo

-Caused by strokes (Vertebral basilar artery insufficiency: patients with vertigo that occurs when they look up [when raising the head compresses the vertebral artery]. ) and tumors -Nystagmus has short latency, a sustained duration, is not fatiguable -Accompanied by other cranial and peripheral nerve deficits

What are the 3 causes of third-degree heart block?

-Caused by: -Ischemia -Medications -Conditions such as lyme disease -Acute ischemia (inferior and anterior STEMI) -Medication adverse effect: -Digitalis -Beta-blockers -Calcium channel blockers

Why should you not use haloperidol and other antipsychotic medications in cocaine intoxication?

-Causes tachyarrhythmia -Lowers seizure threshold. -Worsens hyperthermia.

What are causes, sx's, and treatment for hyperphosphatemia?

-Causes: = causes of hypocalcemia -Hypoparathyroidism, -Renal failure -Increased vitamin D -Many problems associated with ↑Ca++ (from secondary ↓PTH) -K+, Mg++ and phosphate (major intracellular components) travel together, ↓ of one = ↓ of the others -Sx's from associated hypocalcemia and hypomagnesemia -TX: -Oral phosphate binding gels -Dialysis if renal failure -Tx hypocalcemia if necessary

What are causes, sx's, and treatment for hypomagnesemia?

-Causes: Malnutrition, alcoholism, diuretics Sx's: Similar to hypocalcemia and hypokalemia; -Serum levels can be normal in spite of significant deficit -TX: IV magnesium

Patient presents with central facial infection with fever, headache, and vision changes with horizontal diplopia with left eye proptosis and medially deviation of left eye when he looks to the left. What disease is this?

-Cavernous Sinus Thrombosis. - Cranial nerve palsies (III, IV, V, VI - ***VI is classic) -Pupillary dysfunction (mydriasis from III dysfunction) -Classic finding is weakness of cranial nerve VI - abducens palsy.

What is the recommended empiric antibiotic because it covers most of the organisms that cause SBP and because of its high ascitic fluid concentrations?

-Cefotaxime

What are the rattlesnake bite venom effects on humans?

-Cell injury: Swelling, ecchymosis, tissue necrosis, pain -Coagulation system: Increased prothrombin time, INR, decreased platelets, decreased fibrinogen level: DIC -Systemic injury: Capillary leak and myocardial depression (may lead to shock)

What defines hypertensive encephalopathy?

-Central nervous system findings consistent with end-organ damage - not absolute blood pressure

What are the 2 types of diabetes insipidus & how do you differentiate them, and what is the difference in treatment of each one?

-Central vs Nephrogenic -Central: Failure to secrete ADH: -Head trauma -Neoplasm -Pituitary surgery -Nephrogenic: Kidney not responding to ADH -Lithium toxicity -Hypokalemia -Hypercalcemia, -Nephrotoxic drugs -If you give ADH, Central DI will concentrate urine, but nephrogenic DI will not respond. -Tx: -Central = Give ADH Desmopressin (synthetic vasopressin = DDAVP) -Nephrogenic = Hydrochlorothiazide

In following Stroke Syndromes what are the euro deficits? -Cerebral (cortical): ? -Brainstem: ? -Pontine: ? -Cerebellar: ?

-Cerebral (cortical): Contralateral motor and sensory deficits, contralateral cranial nerve palsies -Brainstem: Cranial nerve nuclei (uncrossed) and corticospinal tract (crossed). Ipsilateral facial weakness and contralateral extremity weakness -Pontine: Coma, miosis, gaze paresis, altered respiratory pattern (ataxic breathing) -Cerebellar: Nystagmus, dizziness, N/V, ataxia

-The presence of cerebral symptoms that occur immediately or soon after surfacing from a rapid or uncontrolled ascent is classic presentation of ________.

-Cerebral air embolism -ALOC is the rule and seizures are common -Dive chamber "stat" for treatment

What is possible complication for treatment of HNNS?

-Cerebral edema possibly 2° to rapid fluid replacement or the severity of the condition.

What are Phlegmasia cerulea dolens and phlegmasia alba dolens?

-Cerulean = Blue swelling -Alba = white swelling Uncommon, severe presentation of DVT Massive iliofemoral DVT Acute, severe, massive swelling Cyanotic, congested extremity (cerulea) Pale (alba) if arterial spasm causes "milk leg" I ncreased compartment pressure, ischemia May require surgery for compartment syndrome

What are the risk factors for cervical ca? What is the most common type of cervical ca?

-Cervical Cancer -Risk factors: Early coitus, multiple partners, smoking, HPV, high-risk male partners In HIV patients is an AIDS-defining illness -Squamous type ~ 90%

What is the risk factor most frequently associated with endometritis?

-Cesarean delivery

Benign Positional Vertigo

-Characterized by a lack of associated neurologic deficits and nystagmus with a long latency, transient duration, and fatigability. -most common cause of vertigo and has a peak onset in patients between 50 and 60 years old -Treatment is an otolith-repositioning procedure, most commonly the Epley maneuver. -Osteoporosis, vitamin D deficiency, and a history of prior head trauma have all been associated with the development of BPPV. -Caused by loose calcium carbonate otoliths moving aberrantly within the semicircular canals of the inner ear -Diagnosis can be made with the Dix-Hallpike maneuver -If Dix-Hallpike test is negative, a supine roll test may be performed

What is Reynolds Pentad?

-Charcot's triad 1) Right upper quadrant abdominal pain 2) Fever 3) Jaundice + 4) AMS 5) Hypotension

In all unresponsive patients ALWAYS check _______________.

-Check a rapid blood glucose level

What is alway first test to check in patients with altered mental status?

-Check hypoglycemia

What is the most common complaint of patients with pneumomediastinum.?

-Chest pain

Child has macules to papules to vesicles to crusted lesions at varying stages simultaneously -Has "dewdrop on a rose petal" that come in crops What disease is this, and what medication do you avoid?

-Chicken pox -Avoid salicylates (Reye syndrome) -Complications (mostly adults): Pneumonia, encephalitis, otitis media, 2° infection Treatment: Acyclovir or analogues Prevention: Immune globulin if immunocompromised or pregnant

Patient complains of painful itchy bumps of her fingers and toes about 12-24 hours after cold exposure. What is diagnosis and treatment?

-Chilblains: Painful inflammatory skin lesions, = itchy bumps -Chronic intermittent exposure to damp non-freezing temperatures -Cutaneous symptoms 1-12 hours after exposure Hands, ears, legs, feet -Tx: Rewarming, nifedipine, steroids

What is a CAST fracture?

-Childhood accidental spiral tibia-spiral fractures of the tibia diaphysis common in children who are new at walking. -Fracture of the tibia diaphysis and usually occurs in the DISTAL third but can extend into the midshaft.

Mastoiditis is most common in ______________________.

-Children between 1 and 3 years old. -If you're treating a patient with mild mastoiditis who hasn't taken antibiotics for it yet, start a course of oral antibiotics with close follow-up. -But if oral antibiotics have failed to resolve the mastoiditis, admit the patient for intravenous antibiotic therapy and ENT consultation. -Surgical intervention only after parenteral antibiotic therapy fails.

What are common causes of priapism?

-Children: Sickle cell disease -Adults: injection of medications into the corpus cavernosum to treat erectile dysfunction Other causes: -Antihypertensives -Anticoagulants -Oral agents to treat ED -Some neuroleptic medications.

What are the 4 levels of narrowing that trap esophageal foreign bodies?

-Cricopharyngeus muscle(C6) -Aortic arch (T4) -Tracheal bifurcation (T6) -GE junction (T11)

What is the most common STD in US? How does it present in women and men? How do you dx it? How do you test it? What is TX?

-Chlamydia Trachoma's -Females: Cervicitis, urethritis, PID -Males: Epididymitis, urethritis, proctitis -Consider diagnosis in cases of sterile pyuria A woman treated for UTI with sterile pyruia without relief from UTI abx Diagnosis: NAATs (cultures have low yield), use urine. Don't need to swab urethra in men any longer. -TX: Azithromycin or doxycycline

What are the 2 types of metabolic alkalosis?

-Chloride-sensitive = Chloride loss: Vomiting, diuretics =Volume depletion -Chloride-insensitive -Euvolemia or hypervolemia Excess mineralocorticoids Examples: RENAL ARTERY STENOSIS, RENIN-SECRETING TUMOR.

What sulfonylurea agent causes SIADH?

-Chlorpropamide

What is the most common cause of surgical abdominal pain in the elderly?

-Cholecystitis

A patient eats some grouper, snapper, and barracuda fish and then experiences n/v/d a few hours later followed by paresthesias, reversed temperature sensation(Hot water feels cold). What is the diagnosis & treatment?

-Ciguatera (Gambierdiscus toxicus) -Reef fish (groupers, red snapper, barracuda) Fish eat dinoflagellates containing ciguatoxins -Muscle weakness, paresthesias (perioral, burning hands and feet), distorted or reversed temperature sensation(Hot water feels cold), vomiting, diarrhea -Neuro symptoms worsened with alcohol TX: mannitol, amitriptyline, diphenhydramine Symptoms can last for years. Avoid fish, alcohol

What is the cardinal sign of iritis (AKA Anterior uveitis)?

-Ciliary flush: injection that gives the appearance of a red ring around the iris.

What is treatment for phimosis?

-Circumcision

Patient presents with purpura, anemia, AMS, renal disease, and fever. What is diagnosis?

-Classic TTP(thrombotic thrombocytopenia purpura) pentad: -Fever -Fluctuating neurologic symptoms -Thrombocytopenic purpura, -Microangiopathic hemolytic anemia, -Renal disease -Peripheral smear would reveal fragmented RBCs known as schistocytes similar to HUS. -DON'T do platelet transfusion in TTP! -Treatment of choice: Plasma exchange (plasmapheresis), steroids, FFP

What are the 2 types of heat stroke?

-Classic and Exertional 1) "Classic," nonexertional heat stroke (Old people) -Exposure to high temperature -Epidemic (with heat wave) -Elderly with chronic disease -Not able to sweat, Anhidrosis -Rarely ATN, rhabdomyolysis 2) Exertional heat stroke (Young people) -Results from strenuous exertion (long distance runners, military personnel, football players, manual laborers, adrenergic abuse) -Isolated -Healthy, active -Profuse sweating -DIC -Rhabdo is common -Diarrhea

A patient complains of unilateral sharp and stabbing eye pain, headache with recurrent episodes lasting minutes to a few hours over a period of a few weeks. What is the diagnosis and treatment? Is this sort of HA more common in men or women?

-Classic presentation of cluster headache -Associated symptoms: -Ipsilateral lacrimation -Rhinorrhea -Nasal congestion -Conjunctival injection. -On exam: ipsilateral miosis and ptosis -Tx: High-flow oxygen by nonrebreather mask. -Cluster headache is only primary headache disorder that is more common in men.

How does tinea versicolor (Pityriasis Versicolor) present?

-Classic signs: Hyperpigmented or hypopigmented, scaly lesions on Trunk -But rash can be any color, hence the name

What are risk factors for N. meningitides infection?

-Close living quarters such as dormitories or military barracks, and for that reason it is the most common pathogen in patients younger than 45 years

What is a closed loop obstruction?

-Closed loop obstruction: a specific type of obstruction in which two points along the course of a bowel are obstructed at a single location thus forming a closed loop. -Due to adhesions, a twist of the mesentery or internal herniation. -In the large bowel it is known as a volvulus.

What are the primary headache syndromes, and which one is the most common?

-Cluster -Migraine -Tension -Tension headaches are the most common. -Tension headache - gradual onset of pain, usually described as band-like, and often associated with tightness in the muscles of the neck and shoulders.

Infant has a congenital narrowing of the aorta most commonly at the level of the ductus arterioles. What is the diagnosis?

-Coarctation of the aorta -Often asymptomatic and have normal oxygen saturation levels as blood bypasses the obstruction when the ductus arteriosus is patent. -Has blood pressure and/or perfusion deficits in the upper compared to the lower extremities.

How are cobra envenomation different from rattlesnake bites?

-Cobra bites do not have coagulopathy in the absence of neurologic effects. -Cobra bites DO have: -Immediate pain at the bite site -Neurologic dysfunction (cranial nerve dysfunction, weakness, flaccid paralysis) -Cobra = cholinergic run: Bronchorrhea, salivation, and vomiting

What substances have been reported to cause persistent psychosis for several weeks after cessation of use?

-Cocaine -Amphetamines -PCP

Can you use a beta-blocker with cocaine ?Why or why not?

-Cocaine causes alpha-agonist and beta-agonist stimulation -Beta-blocking medications in acute cocaine intoxication causes rapidly elevated blood pressure due to unopposed alpha stimulation

What is another name for oculovestibular reflex? What is result for following: -Brainstem and Cortex intact = ? -Brainstem intact and Cortex injured = ? -Brainstem injured = ?

-Cold calorics (oculovestibular reflex) -You drive in car. Friend in passenger seat squirts you in ear and you gaze back to him then realize you have to look back at the road quickly to prevent wreck. -Test in comatose patients Patient supine with head elevated 30˚ -Examine external canal first Irrigate ear with ice-cold water -If brainstem and cortex are intact: Nystagmus with fast component directed to opposite ear. "Cold Opposite, Warm Same" = COWS -Cortex injured but brainstem intact: Eyes deviate toward cold ear -Brainstem injured: No eye deviation

What 2 procedures can increase rate of detecting sexual assault injuries?

-Colposcopy -Toluidine application

What is considered normal infant crying?

-Crying that lasts < 3 hours per day -In the afternoon to evening (3 pm-11pm).

What is clinical presentation of toxicity from ethylene glycol?

-Coma -Mild hypothermia -Tachypnea -Blood gas that shows a metabolic acidosis with normal respiratory compensation. (The second two numbers of the pH should be nearly equal to the Pco2.) -Ethylene glycol, typically found in antifreeze, is intoxicating itself and is metabolized, initially by alcohol dehydrogenase, to various toxic metabolites. -Get anion gap metabolic acidosis

Initiation of therapeutic hypothermia is recommended in all patients who remain ______________after resuscitation from cardiac arrest.

-Comatose

What type of female pelvic organ cancer is higher in commercial sex workers vs celibate women?

-Commercial sex workers- high risk for cervical cancer. -Celibate women - more likely to get endometrial cancer.

Patient present with below profile. What is dx? What type of worker is this patient? -Repeated fabrication of disease symptoms for the purpose of gaining medical attention -Voluntary -Hospitalization is primary objective -Demand invasive tests and procedures -Angry at discharge

-Common in healthcare workers -***Distinguished from malingering by willingness to undergo painful procedures

What is Complex Regional Pain Syndrome I? How do you tx it?

-Complex Regional Pain Syndrome I Old name = reflex sympathetic dystrophy -Initiating noxious event or immobilization Pain (burning) or hyperalgesia out of proportion Skin edema, changes in blood flow, abnormal sudomotor activity (sweating changes) -TX: Ganglion block, Bier block, TCAs, gabapentin, clonidine, terazosin, opiates

What 3 type of vertebral fractures are common in motor vehicle collisions, especially with seatbelt use?

-Compression fractures -Burst fractures -Chance fractures

What is cause of carpal tunnel syndrome?

-Compression of the median nerve in the inflamed carpal tunnel between the flexor retinaculum and carpal bones, not at the medial epicondyle

What are the 5 kidney stone Admission Indications?

-Concurrent infection -Concomitant renal insufficiency -Solitary kidney with complete obstruction -Uncontrolled pain or intractable vomiting -Ruptured renal capsule

How do you confirm diagnosis of esophageal candidiasis, and how do you treat it?

-Confirmed with upper endoscopy. -Treated with fluconazole for 2-3 weeks.

If you're treating a patient younger than 3 months who has choking and gagging episodes, consider _____________.

-Congenital malformation of the esophagus.

What are clinical effects of marijuana intoxication?

-Conjunctival injection -Euphoria -Motor incoordination -Sedation -Slurred speech -Tachycardia -Coma and psychosis are rare.

What dx must you always consider in ESRD with altered mental status?

-Consider subdural hematoma in any altered ESRD patient

What is Moritz II, and how do you treat it?

-Constant PR interval and dropped beats -Associated with anterior MI and destruction of conduction tissue -May progress to complete heart block -Temporary pacer often needed in the setting of AMI

What is the most common digestive complaint in US?

-Constipation

What is the classic presentation of infant botulism?

-Constipation followed by an altered neuromuscular examination, with cranial nerve issues noted initially. -Floppy baby, constipation, feeble cry -Deep tendon reflexes are spared and remain normal.

How long do symptoms have to be present for diagnosis of Major depressive disorder?

-Continuously for 2 weeks.

Emetics and neutralizing agents are ____________ in caustic ingestions.

-Contraindicated

What are contraindications to use of nitrates in AMI?

-Contraindicated if sildanefil (Viagra) etc. within 24 hours -Hypotensive -Caution/avoid in RV MI

Infarcts of the middle cerebral artery cause _________________ paralysis.

-Contralateral limb paralysis. -If occurs on the left side of the brain, it may affect the Wernicke or Broca area and result in aphasia.

What is the imaging modality of choice for evaluation of traumatic renal injury?

-Contrast-enhanced CT

How is Conus medullaris distinct from cauda equine syndrome?

-Conus medullar is acute onset. -Has upper motor neuron findings (increased muscle tone) & lower motor neuron findings and is bilateral. -Cauda equina syndrome has gradual onset. -Unilateral - Lower motor neuron symptoms (incontinence or retention, numbness, or weakness) -No recovery potential.

What is best for emergency contraception if it has been more than 120 hours since unprotected sexual intercourse?

-Copper IUD

"Red on yellow kills a fellow" - What snake is this?

-Coral snake

How are coral snakes bites different from rattlesnake bites?

-Coral snakes have small fangs, so not much soft tissue damage -No coagulopathy. -Coral snake venom has primarily neurotoxic effects causing respiratory failure. -Coral snakes "Red on yellow kills a fellow"

What is profile of person with Borderline Personality Disorder?

-Core features: -Unstable in following areas: -Interpersonal relationships -Self-image -Affect(excessive anger, labile) -Marked impulsivity -Suicidal -Do "splitting" = tend to view others as all good or all bad

What cranial nerves are tested with corneal reflex? What is finding if there is brainstem or cortical injury?

-Corneal reflex -Test in awake patients -Test CN V and CN VII (touching the cornea elicits bilateral blink) -Decreased blink in opposite eye suggests brainstem or cortical injury -Lateral gaze Test in awake patients -MLF Medial longitudinal fasciculus connects the oculomotor nuclei and it runs through the brainstem -INO (intranuclear ophthalmoplegia): Eye on affected side can't look at nose see photo. -Bilateral INO = Multiple sclerosis

What is most serious sequelae of Kawasaki's disease?

-Coronary artery aneurysms

What is the mainstay of therapy for Bell palsy?

-Corticosteroids (No antivirals)

What is most common of the TORCH infections?

-Cytomegalovirus (CMV) A member of the herpes virus group (dormant until reactivated) -Congenital: Chorioretinitis, jaundice, ***hepatosplenomegaly, deafness, rash -Acquired: Asymptomatic or mono-like illness -Immunocompromised: CMV retinitis, nephritis, pneumonitis, colitis. -High mortality -Diagnosis: Atypical lymphocytosis, ELISA -Tx: IV ganciclovir or foscarnet

What is the most common vision-threatening condition in HIV? What is second most common eye condition in HIV?

-Cytomegalovirus retinitis -T-cell counts typically below 50 -Blind spots -Visual field losses -Flashing lights -Floaters -TX with anti-CMV meds -(ganciclovir, foscarnet, cidofovir) -Varicella zoster = 2nd most common eye condition in HIV (shingles, 3-4% of patients) -Can involve the retina with retinitis and necrosis (70% get retinal detachment with the necrosis) TX: Acyclovir for 10-14 days

What are doses to treat hypoglycemia? D50 (Adolescent - adults) = ? D25 (2y/o-adolescent) = ? D10 (neonates to 2 y/o) = ?

-D50 (Adolescent - adults) = 2cc/Kg -D25 (2y/o-adolescent) = 4 cc/kg -D10 (neonates to 2 y/o) = 2.5 cc/kg -Glucagon neonates to adolescent 0.03 mg/kg IM/SQ, Adolescent-Adulat 1mg IM/SQ

How can you distinguish osteoarthritis from rheumatoid arthritis?

-DIP joint involvement, it's osteoarthritis. -If there are systemic symptoms, it's rheumatoid arthritis.

What drugs are contraindicated and indicated in A. Fib with WPW? (A-fib with wide QRS complexes rates > 200-250)

-DON'T GIVE Any AV nodal blocker! -Amiodarone -Digoxin -Beta-blockers -Adenosine -Verapamil, diltiazem -GIVE: Procainamide or cardiovert

What are the don't's and do's of treating a rattlesnake bite management?

-DON'T use tourniquets -DON'T Incise and suction not recommended Human oral flora contamination Risk of neurovascular injury Ooze at fang mark is a reliable sign of envenomation -Do use Constriction bands may decrease lymphatic spread of venom -Do use antivenom if indicated. -Death is uncommon

What mnemonic do you run through when you have respiratory decompensation in an intubated patient?

-DOPE: -Displacement of ETT -Obstruction of ET -Pneumothorax -Equipment malfunction.

Seborrheic Dermatitis is AKA ____________. What is profile?

-Dandruff -Localized to hairy skin areas -Malassezia (a fungus) -TX Rotating antidandruff shampoos, ketoconazole shampoo or cream

What is profile of brown recluse spider?

-Dark "violin" top -Woodpiles, cellars -DELAYED pain (opposite of Black Widow bite) -Reclusive "Volcano" lesion -Ischemic necrosis, hemolysis -Ice controversial -Maybe dapsone, HBO, surgery -No antivenin (opposite of Black Widow bite)

What is the primary goal in the medical management of acute aortic dissection?

-Decrease the blood pressure and heart rate to decrease aortic shearing force -Beta blockers -esmolol or labetalol should be given first. -They decrease blood pressure, shearing force, and prevent the reflex tachycardia if add vasodilators.

What is an early symptom of high-altitude pulmonary edema?

-Decreased exercise performance

What are 4 physical examination findings in low back pain that indicate a need for imaging?

-Decreased rectal tone = Possible cauda equine syndrome -Identified level of sensory loss = Spinal cord compression -Asymmetrical pulses or blood pressure = vascular emergency -Fever in the context of midline spine pain = spinal epidural abscess or osteomyelitis

What is the most specific ECG findings of hypertrophic cardiomyopathy?

-Deep, narrow Q waves in the lateral leads.

What is definition of hypothermia? What is definition of mild, moderate, and severe hypothermia?

-Definition: Core temp < 35 oC -MILD hypothermia = 32-35oC (90-95oF) Adjustments to retain and generate heat (shivering thermogenesis) -MODERATE hypothermia = 28-32oC (82-90oF) Slowdown of body functions and metabolism, decreased O2 utilization, CO2 production -SEVERE hypothermia = <28oC (<82oF) Unconscious; apparent death

How do you treat rectal prolapse?

-Definitive management is non-emergent surgery. -Incarceration of the prolapsed tissue is a surgical emergency.

What is Allergic Contact Dermatitis, and how do you treat it?

-Delayed type hypersensitivity Eg. Poison ivy, poison oak, poison sumac (linear --Metal jewelry (nickel) reaction -Hair dyes, detergents -Erythema, pruritus, vesicles, bullae Tx: Corticosteroids for severe cases

Development of altered mental status within hours or days of presentation that change throughout the course of the day (fluctuating mental status over short time course, development over prior hours to days, altered level of consciousness) is a hallmark for ______________.

-Delirium. -Medical causes of delirium are many and varied and include infectious, metabolic, and substance-related conditions. -There is always an underlying organic cause for delirium.

Neurocognitive disorders are also known as _______. How are they classified?

-Dementia -Classified by their presumed underlying cause -Each is associated with varying degrees and types of cognitive impairment and interference with everyday activities.

What is difference between presentation of dementia and delirium?

-Dementia - gradual progressive disease process. -Delirum - acute fluctuating altered mental status over hours to days.

Is succinylcholine a depolarizing or non-depolarizing

-Depolarizing neuromuscular blocking agent

What are the cornerstones of high-altitude pulmonary edema treatment?

-Descent and oxygen administration

How do you diagnose Spontaneous Bacterial Peritonitis?

-Diagnosis: paracentesis with increased WBCs -Neutrophil count > 250 cells/μL

How do you diagnosis & treat infective endocarditis?

-Diagnosis: ultrasound (TEE) for vegetations- ALWAYS pick this -TX: penicillins or vancomycin, and add aminoglycoside ***Add RIFAMPIN for prosthetic valves

What 6 clinical features are associated with a high likelihood for ACS?

-Diaphoresis -Chest pain -Mitral regurgitation -Hypotension -Pulmonary edema -Elevated cardiac serum markers.

What are EKG predictors/signs of reperfusion?

-Early T wave inversions -Accelerated idioventricular rhythm (rate 60-120) -Benign, DON'T give lidocaine to suppress it (Resolves within minutes) Looks like VT but <120 and nl BP: -This is normal after reperfusion from TPA. NO treatment! If give amiodarone will kill patient because causes asystole. -Normalization of ischemia-related ST elevation -Chest pain resolved

What intervention is recommended in patients with stridor or hoarseness from an inhaled irritant?

-Early airway control with intubation

What are the 3 options for definitive management of ascending cholangitis?

-Early biliary tract decompression by: -ERCP -Percutaneous transhepatic cholangiography or -Surgery.

What are echocardiographic findings diagnostic of pericardial tamponade?

-Early diastolic right ventricular collapse -Late diastolic right atrial collapse -Dilated inferior vena cava.

In patients who are treated with shoulder immobilization what is done to prevent adhesive capsulitis of the shoulder (Frozen Shoulder)?

-Early range of motion exercises

What is an early sign for hepatic encephalopathy?

-Early sign is "sleep inversion" (sleeping during the day, awake at night)

In necrotizing fasciitis should radiographic images be obtained?

-Early surgical consultation is urgent and should be pursued before obtaining any radiographic images. -Radiographic testing does not rule out necrotizing fasciitis.

What are the 4 risk factors for ectopic pregnancy? What gestational age does it occur at? What is most common site of the ectopic pregnancy? What is most sensitive diagnostic test for this? What level of HCG should you detect IUP with transvaginal US? for transabdominal US?

-Ectopic Pregnancy Risk factors: -Previous ectopic -PID / IUD -Tubal ligation, pelvic surgery -Infertility treatment Half have NO risk factor Characteristics -5-8 weeks after LNMP, pain, abnormal bleeding -Relative bradycardia may be associated with occult blood loss ***-Distal fallopian tube most common -Indicates IUP on US: -Double gestational sac -Yolk sac or fetal pole -Fetal heart activity HCG Slower than normal increase in HCG Level correlated with US results improves predictive value -***Transvaginal US: Most sensitive, diagnostic in 80% of stable patients -Sonographic discriminatory zone: The level of HCG at which a developing IUP should be seen ***Transvaginal 1500-3000 mIU/ml; should see a gestational sac ***Transabdominal 6000mIU/ml; should see a fetal pole -An US should be ordered if patient at risk for ectopic despite low HCG levels

What is classic presentation of nephrotic syndrome?

-Edema -Proteinuria -Hypoalbuminemia -Hyperlipidemia -Periorbital edema is noted first then have edema of lower extremities and dependent areas (back, sacral, and genitalia)

Propofol should not be used in patients with_____________ allergy.

-Egg or soy allergy.

What are the major risk factors for AAA?

-Elderly male with atherosclerosis, hypertension -Connective tissue disease

How is diagnosis is made of Giant cell arteritis, and what is the treatment?

-Elevated ESR and temporal artery biopsy. -Treatment is IV then oral steroids.

What is most sensitive lab test for heat stroke?

-Elevated LFTs (most sensitive), DIC, increased CPK and myoglobin

What are 3 criteria for diagnosis of spontaneous bacterial peritonitis (SBP)?

-Elevated ascitic fluid absolute PMN (neutrophils) count (≥250 cells/mm3) -Positive ascitic fluid bacterial culture -Absence of secondary causes of peritonitis, such as bowel perforation.

What are side effects of steroid therapy?

-Elevated glucose -Hyperactivity -Insomnia -Hypertension -Weight gain -Osteoporosis -Cataract formation -Oral corticosteroids stimulate cortisol secretion that acts on the liver to release glycogen stores which then increases plasma glucose

What are 4 signs of organ hypoperfusion?

-Elevated lactate level -Decreased urine output (<0.5 mL/kg/hr) -Low mixed venous O2 saturation (<70%) -AMS

What are 3 causes of increased conjugated (direct) bilirubin?

-Elevation of CONJUGATED bilirubin is due to: 1) Biliary obstruction (extrahepatic cholestasis) = stone, tumor, infection, 2) Intrahepatic cholestasis = viral hepatitis, drug-induced hepatitis, cirrhosis, sepsis 3) Hepatocellular injury = CHF

What are the major causes of acute limb ischemia?

-Embolic -Dissection -Atherosclerotic disease Don't forget to consider aortic dissection or AAA

What is difference in physical presentation of acute limb ischemia from emboli vs thrombus?

-Embolus one foot nl and other is lacking pulse, Sudden onset -Thrombus - Both feet have poor pulses Etiology: atherosclerosis (most common) -Develops SLOWLY

What agents are contraindicated in caustic ingestions?

-Emetics and neutralizing agents.

What are the indications for hospitalization of any patients with hepatitis?

-Encephalopathy -PT/INR most important test, INR significantly increased, -Dehydration -Hypoglycemia -Blirubin > 20 -Age> 45 -Immunosuppression

What is the classic triad of Wernicke encephalopathy (WE)?

-Encephalopathy (Altered MS) -Ophthalmoplegia - really Oculomotor dysfunction (Nystagmus, lateral rectus palsy) -Gait ataxia

What medication do you use for HTN emergencies in each of following organ systems? -Encephalopathy, hemorrhagic stroke: - -Ischemic stroke: - -Cardiac: - -Aortic dissection: -

-Encephalopathy, hemorrhagic stroke: -Labetalol -AVOID Nitroprusside - raises ICP -Ischemic stroke: -Nicardipine, labetalol -Cardiac: angina, CHF -IV nitroglycerin -1st line -Add nitroprusside or nicardipine if severely elevated BP -Aortic dissection: -Beta blockers (esmolol, labetalol, propranolol), then nitroprusside or nicardipine

What is the most reliable way to confirm endotracheal intubation?

-End-tidal capnography

What is the most common cancer of the female pelvic organs?

-Endometrial cancer -Dx'd in 10% of patients with postmenopausal bleeding

How do you manage esophageal food impaction?

-Endoscopic retrieval -NO LONGER rec'd!Foley catheter removal. -Glucagon: relaxes lower esophageal sphincter -Nifedipine: reduces lower esophageal tone -Carbonated beverages: gaseous distention may push bolus into the stomach -AVOID MEAT TENDERIZER! (papain)

How do you manage caustic ingestions? What is role of dilution vs gastric decontamination vs neutralization in caustic ingestions?

-Endoscopy is the best diagnostic method -Caustic Ingestions = GI consult -Inconsistent relationship between oral and esophageal findings therefore endoscopy needed! -Gastric decontamination is CONTRAINDICATED! -Dilution (water or milk) can cause vomiting Indicated ONLY for solid alkali ingestions -Neutralization can generate excess heat -Indicated ONLY for hydrofluoric acid ingestions (milk or magnesium citrate)

What does head CT will reveal in patients with normal pressure hydrocephalus?

-Enlarged ventricles.

If you're treating a patient who has recurrent esophageal food bolus impactions and symptoms of gastroesophageal reflux disease despite the use of high-dose proton pump inhibitors, consider ________________________.

-Eosinophilic esophagitis.

What 2 signs are present in epididymitis and absent in testicular torsion? What are the causes of epidydimitis based on 3 age groups?

-Epididymitis Causes: Infection (age-related etiology) Inflammation (e.g. urine reflux) Presentation Can mimic torsion but usually GRADUAL ONSET of pain -Cremasteric reflex usually present (stroking the inner thigh causes retraction of the scrotum and testicle) -Prehn's sign usually present (relief of pain on lifting the testicle) (Ischemic pain of torsion not relieved by lifting) -Age-related factors- for boards. -Young boys: Consider structural abnormality / E. coli -Sexually active: Usually STD-related (Chlamydia/GC) -Older patients: Think obstruction, prostatism / E.coli

What is the most common form of HSV keratitis? What are other forms?

-Epithelial keratitis manifesting with the classic dendrites -Other forms: -Disci form -Stromal -Keratouveitis -Disciform keratitis: deeper, disc-shaped, localized area of corneal edema. -Pain and decreased vision. -History of orolabial or genital herpes infections

- Teenager presents with fever, exudative pharyngitis, splenomegaly & posterior lymphadenopathy. CBC shows atypical lymphocytosis What is diagnosis and treatment?

-Epstein-Barr virus (EBV) - in adolescents. Usually asymptomatic in infants and children -Complications: Splenic rupture, thrombocytopenia Diagnosis: Monospot, serology Amoxicillin almost always causes a maculopapular rash (may be diagnostic) Tx: Rest, supportive, no contact sports

Ergotamine (DHE) and Sumatriptan are : contraindicated in which patients?

-Ergotamine, DHE: contraindicated in CAD, PVD, HTN, RF, pregnancy b/c it's alpha constrictor -Sumatriptan: Contraindicated in heart disease, HTN

-Toddler presents with fever, diarrhea, & URI symptoms and bright red cheeks, What is diagnosis & treatment? What is complication that can occur with sicklers?

-Erythema Infectiosum (Fifth Disease) -5th disease think 5 fingers on hand=slap face (slapped cheeks), tiny papules on erythematous base, eyelids and chin spared -Human Parvovirus B19. Rash: Abrupt onset, bright red cheeks, Complications: Arthritis, aplastic crisis (especially in sicklers) -Cause fetal anemia during pregnancy -Tx: NSAIDs

What is Erythema Multiforme, and how do you treat it?

-Erythema Multiforme part of spectrum of same disease of SJ and TEN -Minor (erythema multiforme) → EM major (Stevens-Johnson) → EM maximum (TEN) Hypersensitivity reaction Infection (Mycoplasma, Herpes), malignancy, drugs -Memory aid: "SOAP" - Sulfa, oral hypoglycemics, anticonvulsants, PCN -Palms, soles, extensor surfaces "Bull's eye" or "target" lesions -TX: Remove offending agents; symptomatic for minor forms; major forms may need resuscitation, ICU admission

What peculiar rash occurs with Lyme disease along with other disease processes? How do you treat it?

-Erythema migrans: Annular, expanding erythematous lesion with central clearing (spares palms, soles) -Neuro: could be bilateral CN VII palsy, meningitis, peripheral neuropathy -Cardiac: Myocarditis, pericarditis, heart block Diagnosis: ELISA (screening); Western blot TX: Doxycycline, amoxicillin, cefuroxime; macrolides if others not tolerated Probable risk = Test Probable disease = Treat

What is profile of psoriasis?

-Erythematous thick plaques with white (silver) scales -Extensor surfaces of elbows, knees, scalp, palms, soles -Pitting of the nails -Can have psoriatic arthritis -TX: steroids, tar, UV light, methotrexate

What is the most common cause of HUS in children?

-Escherichia coli infection of the digestive system -Shiga toxin producing E. coli 0157:H7 -From eating undercooked meat, unpasteurized milk, and contaminated fruits and vegetables

Patient presents with white plaques in the posterior pharynx with associated odynophagia. What is diagnosis, and what type of patient has this?

-Esophageal candidiasis -Immunocompromised patients, such as HIV/AIDS or cancer with neutropenia.

-Amyotrophic Lateral Sclerosis (ALS)

-Etiology unknown -BOTH UPPER & LOWER MOTOR NEURONS DEGENERATION -Muscle wasting & fasciculations -Weakness -Difficulty eating & swallowing -Diagnosis: Upper and lower motor neuron symptoms, EMG -Upper motor neuron disease: Spasticity, no sensory deficits -Lower motor neuron disease (anterior horn cells): Atrophy, fasciculations -Slowly progressive, death 2˚ respiratory failure

What must you be cautious of in the initially asymptomatic patient suffering a primary biast injury?

-Even the initially asymptomatic patient might decompensate. -Serial observation of pulmonary status with pulse oximetry checks and examination is generally recommended.

What are 3 criteria for definition of septic shock?

-Evidence of infection -Hypotension of a MAP < 65 mm Hg despite fluid resuscitation -Lactate > 2 mmol/L.

CT is excellent at identifying injuries to _______ and __________, but __________ and ____________________ are often missed on CT.

-Excellent at identifying injuries to bone and solid organs -Pancreas and hollow viscus injuries are often missed on CT.

What are the causes of Cushing's syndrome (Hyperadrenalism)?

-Excess cortisol from: -Prolonged steroid use (most common) -Adrenal neoplasm, pituitary microadenoma -ACTH-secreting carcinoma (small cell, pancreatic, bronchial carcinoid)

How does hypertrophic cardiomyopathy present?

-Exertional syncope -Sudden death -Murmur louder with decreased preload (hypovolemia, standing, Valsalva, amyl nitrite, beta agonists) (Movement that decreases LV filling and increases obstruction) -Murmur decreased with increased afterload (squatting, Trendelenburg, hand grip, volume expansion, alpha agonists) (Movement that increases LV filling decreases obstruction) Mnemonic - person stands up to block passage of another person - He OBSTRUCTS = Increased murmur and turmoil -Person sits down and relaxes and lets everyone pass by. Decreases murmur and toil.

What is syringomyelia, and what are the neuro deficits? - Know this.

-Expanding central cavity in spinal cord Post-traumatic (e.g., whiplash,) -Post-infectious -Idiopathic -Usually involves cervical cord -Intraosseous muscle wasting -so poor grip -Loss of pain/temperature sensation in hands (vibration/position preserved) "hold a cigarette but when burns down can't feel it." Associated with cerebellar (Chiari) defects -DX by MRI

Why do you need to get a hand surgery consultation if a fingertip amputation reveals exposed bone?

-Exposed bone in a fingertip amputation indicates that the injury can lead to significant complications and even death. -Can lead to osteomyelitis -Poor sensation -Cold intolerance -Poor function.

What are the 3 types of radiation exposure?

-External (e.g. radiation therapy) -Internal (inhalation, ingestion) -Contact with skin and clothes requires decontamination

What do following FDA safety categories mean? -C ? -D ? -X ? At what gestational age is greatest teratogenic risk?

-FDA safety category: -C: possible adverse effects (animal studies), use if benefit outweighs risk -D: use only in life-threatening emergencies with no alternative -X: do not use -Teratogenic risk is greatest at 4-12 weeks

Strokes of the middle cerebral artery: -Weakness limbs ___________________to the lesion -Gaze deviation and hemianopsia ___________________ to the lesion -Upper extremities and face affected __________________ than lower extremities.

-Face & Limb weakness CONTRALATERAL to the lesion -Gaze deviation and hemianopsia IPSILATERAL to the lesion -Upper extremities and face affected > than lower extremities. -Left MCA: -Right hemiparesis -Right homonymous hemianopsia -Aphasia -Right MCA: -Left hemiparesis -Left homonymous hemianopsia -Left hemineglect if non-dominant

What factor deficiency occurs in Hemophilia A?

-Factor 8

Do you use factor IX to treat von Willebrand or Hemophilia B?

-Factor IX is deficient in hemophilia B and is not associated with von Willebrand disease.

Malingering = ?

-Fakers -Motivated by external incentives -Frequently associated with litigation -Marked disparity of symptoms with objective findings -Lack of cooperation with evaluation -Often antisocial behavior or substance abuse

What conditions associated with false colorimetric or capnographic readings?

-False-negative reading: -Low pulmonary perfusion: -Cardiac arrest -Inadequate chest compressions during CPR -Massive pulmonary embolism -Massive obesity -Severe pulmonary edema: secretions might obstruct the tube -False-positive reading: -Carbonated beverage, but should not persist beyond six breaths -Heated humidifier, nebulizer, or endotracheal epinephrine, but transient

Nonunion of the clavicle is rare after fracture. True or False?

-False. Nonunion of the clavicle is not uncommon. -Comminuted fractures can lead to nonunion. -30% of lateral clavicle fractures involving a torn coracoclavicular ligament result in nonunion and require surgical repair.

What diagnosis must you consider in any patient with respiratory distress following a long bone fracture or other significant orthopedic surgery or trauma?

-Fat embolism syndrome

What is the most common transfusion reaction and how do you treat it?

-Febrile nonhemolytic transfusion reaction Most common transfusion reaction -Fever and chills Due to interaction between recipient and donor non-RBC components -May be hard to distinguish from early acute hemolytic reaction -Must stop transfusion and exclude hemolysis

What are the most common presenting seizure disorder in children?

-Febrile seizures -Result from a temperature > 38°C (100.4°F)with no evidence of intracranial infection or other defined cause or neurologic disease.

What are the clues to rectal prolapse?

-Fecal incontinence -Constipation -Abdominal discomfort -Prolapsed anal mass

How is hepatitis A transmitted, and how do you treat it?

-Fecal-oral transmission, contaminated water or food. Not associated with chronic carrier state -Prophylaxis: Hep A vaccine -Get Immune globulin within 2 weeks of exposure (travellers, household contacts)

What are risk factors for Intimate partner violence (IPV)?i

-Female sex -Pregnancy, -Low income level -Separated status (as opposed to married or divorced) -Age 18-24 years.

What is most common hernia in women?

-Femoral: common in women. Incarceration and strangulation more likely than in inguinal hernia ***Most comm hernia in women is inguinal! DON'T BE TRICKED.

What is the classic triad of spinal epidural abscess?

-Fever -Back pain -Neurologic deficits The triad occurs only in small percentage of patients with spinal epidural abscesses.

What is the classic triad for septic arthritis?

-Fever -Joint swelling -Restricted range of motion

What are the symptoms & presentation of Rocky Mountain spotted fever?

-Fever -Myalgias -Headache -Abdominal pain -Macular rash that starts on the extremities, spreads to the torso, and later becomes petechial. (Begins on the ankles and wrists and spreads to the trunk. May include palm/soles)

What are the findings of endophthalmitis? What are most cases of endophthalmitis caused by? What is tx?

-Fever -Redness -WBC's/Hypopyon in the anterior chamber -Hazy cornea -Most cases are post-surgical from intraocular procedures -Usually Gram + TX: Bacterial: Vancomycin and gentamicin or 3rd generation cephalosporin Fungal: Amphotericin B

What is highotuput heart failure, and what are the causes of this?

-Heart has nl C.O. but metabolic demands are higher. -Thyrotoxicosis -Anemia -A-V fistula -Paget's disease of the bone -Beriberi

What is the physical characteristic of fibrocystic changes in a woman's breast vs cancer?

-Fibrocystic changes: -Nodular -Mobile -Smooth -Can become tender with menstrual cycle changes -Cancerous lesions: -Firm -Irregular in shape. -Enlarged lymph nodes associated with breast cancer initially are rubbery

How do carotid and vertebral artery dissections present?

-First Headache and neck pain, Then neurologic symptoms.

What is risk of cross reactivity in patient allergic to amoxicillin to first-generation, third- and fourth-generation cephalosporins?

-First-generation cephalosporins such as cephalexin have the greatest risk of cross reactivity with penicillin. -Third- and fourth-generation cephalosporins possess very low risk of cross reactivity.

18 y/o female on pelvic exam has CMT & RUQ tenderness. What is dx?

-Fitz-Hugh-Curtis syndrome -Purulent material spills from tubes into abdomen Direct or lymphatic spread -Bacterial perihepatitis -LFTs normal Right upper quadrant and shoulder pain "Violin string" adhesions around the liver

What is classic physical finding of flail chest?

-Flail segment moving paradoxically inward during inspiration.

How does the dentate line anatomically delineates complexity and the need for surgical consultation?

-Fluctuance above the dentate line indicates the need for surgical consultation. -An abscess below the dentate line may be treated in the emergency department with incision and drainage.

How do you manage fluid resuscitation in setting of pulmonary contusion?

-Fluid resuscitation with crystalloid to euvolemia appears appropriate -Over-resuscitation with intravenous fluids can lead to additional pulmonary edema and hypoxia.

When and how long do you give Post-exposure prophylaxis

-For HIV-positive exposures or high risk exposures. -Start meds within 1-2 hours of exposure -Multi-drug protocols for 4 weeks are standard

When is postexposure prophylaxis recommended for infants?

-For infants younger < 6 months who are household contacts with confirmed pertussis infection because they have not completed the recommended immunization regimen.

When is it indicated for either antibiotic therapy or observation with close follow-up for acute OM?

-For nonsevere acute otitis media in children < 2 y/o

For what type of burn is occlusive dressing indicated?

-For partial-thickness burns -If the wound has a moist surface or unroofed blisters or is insensate, occlusive dressing can be considered.

What is treatment for Hemophilia A and Hemophilia B with severed life-threatening injury? What is treatment for mild Hemophilia B bleeding?

-For severe, life-threatening CNS bleeding always give 50 units/kg of factor VIII. -This replaces 100% of factor VIII (factor8). -For hemophilia B, give 100 units/kg of factor IX (factor 9) to raise the factor IX level to 100 percent. -DDAVP - desmopressin (a synthetic replacement for vasopressin [ADH]) with any CNS complaints) -Releases of VWB factor from endothelial storage sites - the VWB factor carries extra factor VIII in the plasma and increase its survival.

What is Hamman crunch?

-Found in pneumomediastinum. -Crackling, crunching, rasping sound, synchronous with the heartbeat, heard over the precordium during systole -Caused by the movement of air in the mediastinum

What is Fournier's Scrotal Gangrene? When do you consider this?

-Fournier's Scrotal Gangrene=necrotizing fasciitis -Surgical emergency -Begins as benign infection (cellulitis, abscess) -Consider with scrotal, rectal or genital pain out of proportion to clinical findings

What is necrotizing fasciitis involving scrotum, vulvar or perianal skin?

-Fournier's gangrene

What are contraindications to IO access?

-Fracture of same bone, -Previous IO attempt on same bone -Inferior vena cava injury -Osteogenesis imperfecta -Osteopetrosis (hyperdense bone prone to fractures) -Overlying cellulitis.

Why do patients with Addison's disease have hyper pigmentation? (Think JFC)

-From high ACTH

What occurs with Acute hemolytic transfusion reactions and how do you treat it?

-From infusion of incompatible RBCs = ABO incompatible reaction -RBCs are rapidly destroyed by antibodies get reaction of fever, chills, hypotension Then b/c have free hemoglobin and RBC stroma in the blood stream that clog up kidney get ATN, breathlessness, respiratory failure, hemoglobinuria [pink urine] TX: -STOP TRANSFUSION -Hydrate to diurese -Symptomatic -Lab: -Free hemoglobinemia and hemoglobinuria -Haptoglobin (binds to free hemoglobin) is decreased -Coombs testing of pre- and post-transfusion blood (a test for globulin antibodies on the surface of RBCs)

What are the 4 degrees of frostbite?

-Frostbite similar to burn just with cold -1st degree: Superficial, erythema, NO BLISTERS -2nd degree: FULL thickness, edema, erythema, CLEAR BLISTERS -3rd degree: BLOODY BLISTERS, "Bloody is bad" Hemorrhagic blisters, skin necrosis -4th degree: Extension to bone -Early clear blebs = GOOD -Early hemorrhagic blebs = BAD

What is the difference between frostbite vs frostnip?

-Frostbite: Local tissue freezing (irreversible) -Frostnip: Transient freezing (reversible)

What is Boerhaave syndrome?

-Full-thickness perforation of the esophagus. -Presents with sudden, severe, unrelenting chest pain that might radiate to the neck, back, shoulders, and abdomen. -Can be associated with subcutaneous emphysema due to pneumomediastinum.

What is difference in clinical presentation between functional and organic disorders for AMS in following areas? -Age -Orientation -Type of hallucination -VS

-Functional(psychiatric) -Age 15-40 years -Gradual onset -Clear sensorium -Auditory hallucinations -Oriented -Organic -Onset <12 or >50 -Acute onset, fluctuating course -Disoriented -Visual and tactile hallucinations -Abnormal vital signs -Substance abuse

What are the 2 most vulnerable organ systems in radiation exposure?

-GI & heme

_____________________________ is responsible for most cases of peptic ulcer disease.

-Helicobacter pylori

What is Erythroderma (exfoliate dermatitis)?

-Generalized erythema that affects more than 90% of the skin followed by scaling and sloughing. -Intensely tender and pruritic. -Loss of both hair and nails. -Treated as burn victims. -All require admission for fluids and electrolytes & pain control and infection & cancer workup and wound care. -Associated with skin and connective tissue disorders, cancer, medications, and heavy metals.

What is Exfoliative Dermatitis, and how do you treat it?

-Generalized, diffuse, scaly, warm, erythematous, non-tender, pruritic rash all over body -Leads to exfoliation -Most are secondary to underlying disease -Response to drugs or malignancy (lymphoma, leukemia) -Complications are 2° to disruption of epidermis Hypothermia, volume loss, electrolyte abnormalities, 2° skin infection Important to diagnose underlying cause -Admit, IV, steroids for severe cases

What is the most common sexually transmitted disease in the United States? Which type of HSV is most common in US? When does primary lesion of herpes occur after contact? When can you shed the herpes virus? What is best test?

-Genital herpes -HSV-2 (more common in U.S.) or HSV-1 -1 in 5 sexually active adults infected -Primary lesion at 2-7 days after contact (shallow, painful vesicles clustered on erythematous base, then ulcerations -Can shed virus during recurrences as well as during asymptomatic periods -Viral PCR best test at this point -Viral tissue culture gold standard

What happens to kidney function with hypothermia?

-Get cold-induced diuresis from distal collecting tubule dysfunction

What are signs and sx's of hypocalcemia, and what is the treatment?

-Get twitchy and jerky Signs & Symptoms -Paresthesias, hyperreflexia, seizures -Chvostek's sign: Twitch of corner of mouth on tapping facial nerve in front of ear Chvostek -CH = Cheek -Trousseau's sign: Carpal spasm when BP cuff is inflated above systolic BP -EKG: PROLONGED QT / inverted T waves -Tx: -Calcium gluconate -Magnesium

Patient has gone camping, and now he has forceful diarrheal episodes with stool described as foul-smelling and pale. -Abdominal distention with intermittent abdominal pain and frequent flatulence -Audible borborygmi, or stomach rumbling What is diagnosis?

-Giardia lamblia infection

What is the most common protozoal infection in the US, and when do you suspect it?

-Giardiasis -Occurs in hikers and campers who drink contaminated water -Adults and children in child care centers -Those who engage in oral-anal sexual -Symptoms: -Diarrhea -Excessive flatulence -Abdominal bloating.

What is the most frequently diagnosed parasitic infection in the United States, and what is test of choice to confirm it?

-Giardiasis -Stool antigen is the test of choice for confirming the pathogen because it is consistently present in stool, regardless of Giardia cyst shedding (which is more variable).

What is the most common malignant tumor of the CNS?

-Glioblastoma multiforme -Appears as an irregular mass with surrounding edema.

Why is principal manifestation of acute isoniazid poisoning is convulsions?

-Glutamate, the main excitatory neurotransmitter in the CNS is converted by a pyridoxine-dependent pathway to GABA -Combination of too much excitatory glutamate and not enough inhibitory GABA leads to convulsions that can be refractory to benzodiazepines (benzodiazepines require the presence of GABA to work).

What is goal in treating BP in hemorrhagic stroke? What medications do you use, and which one do you avoid using?

-Goal is to control BP but maintain cerebral perfusion pressure -Labetalol (preserves cerebral blood flow) -Nicardipine -AVOID NITROPRUSSIDE (raises ICP)

How do you treat severe hyponatremia (Na+ < 120 PLUS CNS abnormalities)?

-Goal is to raise level to >120 mEq/L Rise in Na+ should be no greater than 0.5-1.0 mEq/L per hour (1-2 mEq/L per hour if seizures) -Hypertonic saline (3%) 25-100 mL/hr -Furosemide (Lasix) 20-40 mg IV -Too-rapid correction -CHF -Central pontine myelinolysis (CPM) (HyPonatremia if corrected too fast get pontine myelinolysis

What type of septic arthritis is the most common form of septic arthritis in adolescents and young adults, and how do you test for it?

-Gonococcal -Do arthrocentesis, BUT < half of joint fluid cultures are positive for N. gonorrhoeae infection, so you need to get cultures from posterior pharynx, urethra/cervix, and rectum.

What is difference in presentation of gonococcal arthritis vs gout vs Lyme?

-Gonococcal arthritis = migratory arthritis (think random joint pain) in young female -Gout = monoarticular or toe or knee in 40+ y/o patient -Lyme can be either, or it can start as polyarthritis and evolve into monoarthritis.

What is difference in treatment of gonococcal arthritis vs nongonococcal septic arthritis?

-Gonococcal arthritis may be treated with intravenous third-generation cephalosporin - and avoid surgical joint irrigation -Nongonococcal septic arthritis requires surgical management and joint irrigation

Adult 30 y/o male presents with white penile discharge. Gram stain of discharge shows gram negative intracellular diplococci. What is dx and tx?

-Gonococcal urethritis -Treatment: ceftriaxone 250mg IM Treat for Chlamydia as well

What is most common cause of septic arthritis in pts. <50 y.o.?

-Gonorrhea

What bacteria is Gram Negative Diplococci? How do you dx & tx it?

-Gonorrhea Diagnosis: NAATs TX: Single dose therapy Ceftriaxone 250 mg IM PLUS Azithromycin 1 gm PO once -OR- doxycycline 100 mg PO twice a day for 7 days

T wave inversion: within 4 hours is ________Px sign.

-Good

How does vibrio infection present?

-Gram negative rod, rapid infection -Hemorrhagic bullae, Pain, swelling, , vasculitis, necrotizing fasciitis, sepsis -Alcoholics or patients with liver disease have severe infection, person opening oysters or wound in feet in ocean water. -Abx: Ciprofloxacin, bactrim, tetracycline

Tea-colored urine with oliguria = ?

-Hematuria with oliguria = kidney disease -Add pharyngitis, edema, hematuria and proteinuria all = Poststreptococcal glomerulonephritis

What are causes of Hypothyroidism?

-Treatment of Graves' disease -Iodine deficiency in diet -Autoimmune destruction of thyroid gland (e.g. Hashimoto's) -Lithium therapy for bipolar disorder -Amiodarone

Male patient presents with painless ulcers of penis that progresses and mutilates. Penis is essentially eaten up. There is no inguinal adeopathy. What is DX, organism, and treatment? What do you see on biopsy of lesions?

-Granuloma Inguinale Calymmatobacteruim granulomatis (Donovaniasis) Penis is eaten up and goes away Rare in U.S. Presentation: -Chronic painless progressive ulcers and vascular granulomata Multilating -No inguinal adenopathy -Biopsy! (Donovan bodies) -TX: doxycycline x 3 weeks

What is pyogenic granuloma also referred to in pregnant patients?

-Granuloma gravidarum -Neither name is accurate. - It is benign collection of capillaries. -NOT granulomatous, purulent, or infective -Lobular capillary hemangioma is a better term.

What is most common cause of hyperthyroidism?

-Graves' disease (most common): An autoimmune disorder (thyroid-stimulating immunoglobulins mimic the action of TSH) -Other causes: -Toxic thyroid adenoma, toxic multi-nodular goiter -Thyroiditis -Pituitary adenoma -Excess iodine in diet

Thrombolysis vs. percutaneous coronary intervention?

-Guidelines recommend PCI if balloon inflation can be performed within 90 minutes -Window of benefit over lytics extended if chest pain > 6 hours or if cardiogenic shock

When you find ascites in a female you must r/o ______________.

-Gynecologic neoplasm (e.g., ovarian cancer)

What are 3 environmental causes of NON-CARDIOGENIC heart failure?

-HAPE -Thermal injury -Drowning

What do each of these markers mean? HB Surface antigen = ? HB Surface antibody = ? HB e antigen = ? HBcAb = ?

-HB Surface antigen = Infectious S antigen = Sick & Infectious with Hep B -HB Surface antibody = Protective Antibodies = Has immunity = protection -HB e antigen = Highly infectious E = Extra infectious HBcAb= persists for life. Best indicator of history of HBV infection

What is often the initial presentation of NIDDM?

-HHNS - Hyperosmolar Hyperglycemic Non-ketotic State

A clear chest xray has a high negative predictive value except in _______ patients, in whom it can be falsely negative.

-HIV-positive

What is most common cause of low output heart failure?

-HTN is #1 Other causes: -Coronary artery disease, MI -Valvular heart disease -Cardiomyopathy (i.e. ischemic)

How do you distinguish HUS from TTP?

-HUS has diarrhea and renal failure -TTP has neurologic sx's

What is difference between HUS, TTP, & DIC? What are the similarities?

-HUS: TTP DIC Age: Children Adults Adults CBC: Anemia LowHgb& plts l owHgb &plts Smear: MAHA* MAHA MAHA Clinical:Renal/Diarrhea CNS Underlying illness TX: Supportive Plasmapheresis/ Heparin steroids &blood products Prognosis: Good Poor Poor *Microangiopathic Hemolytic Anemia

What are the 3 types of hyponatremia?

-HYPOVOLEMIC hyponatremia = dehydration -Na+ loss > free water loss -GI losses (vomiting, diarrhea) -Renal losses (diuretics) -Excess skin losses (sweating, burns) -HYPERVOLEMIC hyponatremia = edematous states -CHF (decreased effective circulating volume leads to ADH release) -Liver cirrhosis (same as CHF) -Renal disease (nephrotic syndrome, renal failure) -Decreased free water excretion -EUVOLEMIC hyponatremia -SIADH (syndrome of inappropriate ADH secretion) -Psychogenic polydipsia -Hypothyroidism

What STI presents with painful genital ulcers and unilateral inguinal lymphadenopathy (bubo)?

-Haemophilus ducreyi infection - gram (-) bacillus -Rash is Chancroid. -Tx: Azithromycin 1 g PO or rocephin 250mg IM

What is presentation of esophageal candidiasis, and what is profile of patient?

-Hallmark is odynophagia or pain on swallowing. -New odynophagia or oral thrush and concomitant odynophagia. -Most common in HIV-infected patients or any immunocompromised patient

What are 2 CXR findings associated with PE?

-Hampton hump: -Pleural-based wedge-shaped area of infiltrate -A peripheral infarct -Westermark sign: -Unilateral oligemia -A sharp cut-off of pulmonary vessels with distal hypoperfusion in a segmental distribution within the lung

Child presents with fever, sore throat, malaise, URI and painful vesicles on anterior mouth (buccal mucosa, tongue, soft palate, gingiva) & red papules (change to gray vesicles) on palms & soles. What is diagnosis?

-Hand-Foot-Mouth Disease -Coxsackie virus (enterovirus) -Occurs in outbreak -Fecal-oral transmission -Vesicles on hands, feet, soles -Avoid viscous lidocaine in young children because of risk of seizures

What distinguishes alcoholic ketoacidosis associated with malnourishment from poisoning with a toxic alcohol?

-Has a normal mental status despite the presence of potentially severe acidosis.

What is special about labetalol?

-Has alpha and beta blocker (primarily beta, 7x's more beta than alpha, so if need alpha not that good for alpha) -Low doses may lead to paradoxical hypertension due to predominant beta effect (unopposed alpha) -Contraindicated in bronchospasm, CHF, AV-blocks

What type of tachyarrhythmias does cocaine cause?

-Has sodium channel-blocking properties that lead to ventricular wide-complex tachyarrhythmias.

Why is lidocaine contraindicated in cocaine toxicity?

-Has sodium channel-blocking properties, so can potentiate wide-complex tachycardia, -Potentiate cocaine toxicity -Decrease seizure threshold.

What are 6 indications for urgent endoscopy for swallowed foreign bodies?

-Has: -Airway compromise, -Perforation -Presence of a foreign body> 24 hours or ingested: -Multiple foreign bodies -Ingestion of sharp or elongated objects -Button batteries

What are the indications for rattlesnake bite antivenom?

-Have signs of envenomnation -Progression of local injury -Pain, swelling, ecchymosis -Coagulopathy -Prolonged PT or INR, low platelet count, low fibrinogen level -Systemic effects: -Hypotension, confusion, n/v, fasciculations, paresthesias

What is the Lund-Browder chart for pediatrics?

-Head & Neck= 20 % TBSA -Each Arm = 10 % TBSA -Each leg = 10 % TBSA -Anterior trunk = 20 % TBSA -Posterior trunk = 20 % TBSA

Coarctation of aorta

-Upper & Lower extremity blood pressure differential

If you have pink urine and have hematuria, then what is your ddx? If you have pink urine and no hematuria, then what are the 2 possibilities, and what is ddx of each of them?

-Hematuria: Think: -Kidney stone -Cancer -Nephritic syndrome -Pink urine with No hematuria: 1) Myoglobinuria = Rhabdomyolysis 2) Hemoglobinuria = -Intravascular hemolysis -MAHA - DIC, TTP, HUS -Mechanical Valve -Transfusion reaction

What are the 2 indications for emergency pacing?

-Hemodynamically unstable bradycardia -Overdrive pacing of refractory tachy (e.g. tornadoes) "STANDBY" pacer -Mobitz II or CHB that is stable (for now!) -New BBB in symptomatic patient

What is the most common cause of acute kidney injury in children?

-Hemolytic uremic syndrome (HUS)

Child has GI symptoms (nausea, vomiting, bloody diarrhea) and a low-grade fever, and develops kidney failure, and neurologic symptoms, such as seizures and encephalopathy. Vital signs shows hypertension. CBC shows anemia and low platelets. Peripheral smear shows schistocytes (helmet cells) Chem 7 shows elevated BUN/Cr. What is the disease, and treatment do you avoid?

-Hemolytic uremic syndrome (HUS) -AVOID Antibiotics and antimotility agents -Classic triad: -Microangiopathic hemolytic anemia -Thrombocytopenia -Acute kidney injury.

How do you distinguish between Hemophila A and Hemophilia B, and which one is the most common variant? What are the most common cause of death from bleeding in hemophiliacs? How are PT and aPTT affected in hemophilia?

-Hemophilia A = Factor VIII because "A" sounds a lot like the word "eight" H-A is the most common variant. 85% of hemophiliacs -Hemophilia B = Factor IX because "A" comes before "B" and "8" comes before "9", H-B = 15% of hemophiliacs -CNS - IC bleeds are the most common cause of death from bleeding - can be spontaneous -Normal PT, increased aPTT, decreased factor VIII or IX

What symptom does pulmonary contusion commonly present with?

-Hemoptysis.

Tetrad for __________________. ●Palpable purpura in patients with neither thrombocytopenia nor coagulopathy ●Arthritis/arthralgia ●Abdominal pain ●Renal disease

-Henoch-Schönlein Purpura

6 y/o child has recent strep infection and now presents with abdominal pain. She has developed a Palpable purport on her buttocks and legs and complains of joint aches. What is the diagnosis and treatment?

-Henoch-Schönlein Purpura -Most common acute vasculitis affecting children Preceded by Strep or GI infection (Salmonella, Shigella) -Ages 2-10, abdominal pain, GI bleeding, hematuria Palpable purpura (legs, buttocks) -NO Thrombocytopenia is absent -NOT a platelet problem Complications: Arthritis, glomerulonephritis, hematuria, GI bleeding, INTUSSUSCEPTION -Renal consult -Usually resolves spontaneously

What is role of heparin, beta blockers and platelet inhibitors in acute AMI?

-Heparin (Unfractionated or LMWH): GIVE THIS CARD CATH -Beta blocker (metoprolol) - NO early IV (discouraged) Give within 24 hours orally but no rush HAVE BACKED OFF using beta blockers in acute setting. -Platelet inhibitors (in ED or cath lab) GP Ilb/IIIa receptor antags IV load -Clopidogrel, ticagrelor: CAN GIVE oral load -Prasugrel 60 mg oral load AT CATH; AVOID if history of TIA or stroke

What are profiles of Hep Delta, Hep E, and Hep G?

-Hepatitis delta (HDV): Requires HBsAG for co-infection - Can only get D if get B. -IV drug users, homosexual patient population, hemophiliacs / high likelihood for sequelae -Hepatitis E Virus Oral-fecal transmission -In Asia, Africa, Russia -Hep G Virus: blood transfusions, sexual contact

Child presents with abrupt with high fever (38.9°C to 40°C [102°F to 104°F]) with a seizures at home. Now toddler is alert and oriented. He is fussy and complains of sore throat and dysphagia. On exam of throat you find ulcerative lesions (vesicles rupture, leaving painful ulcers on posterior pharynx, soft palate, uvula. Anterior mouth is spared. What is diagnosis and treatment?

-Herpangina -Coxsackie virus -Fecal-oral transmission(enterovirus) -Fever, dysphagia, drooling, vomiting, headache Ulcerative lesions (vesicles rupture, leaving painful ulcers on posterior pharynx, soft palate, uvula) -Resolves in 1 week -Tx: Self-limited: supportive

What is an important distinction between rash of genital herpes and syphilis?

-Herpes has painful multiple grouped ulcers. -Syphilis has painless skin lesions along with systemic symptoms such as fever and malaise.

In patients with fertility assisted pregnancy with abdominal pain and vaginal bleeding what dx should you consider?

-Heterotopic pregnancy = 1 is IUP and 1 is ectopic.

High or pulmonary artery pressure due to hypoxia is an essential component in the development of HAPE?

-High (not low) pulmonary artery pressure.

What are the symptoms and risk factors that differentiate necrotizing external otitis (formerly known as malignant otitis external from the more benign form of otitis external?

-High fever (>38.9⁰C) -Meningeal signs -Severe otalgia.

What is difference in treatment of high voltage vs low voltage (Household exposures)?

-High voltage >1,000 volts: Admit 24-48 hours of monitoring. Look for development of compartment syndrome and rhabdomyolysis. -Low voltage <1,000 volts (Household exposures): No cardiac complaints, normal ECG, no cardiac disease - safe to discharge

What is considered high voltage for electrical injury, and what arrhythmia occurs?

-High voltage: >1000 V Significant injury and death >600 V -US power lines 7620 V -3rd rail subway 600 V -Lines entering house 220 V -Household sockets 110 V -High voltage injury: Skin burns severe Violent skeletal muscle contraction, throw victim so TRAUMATIC injuries -Fractures, dislocations (posterior shoulder) Clinical picture resembles crush injury -High voltage AC/DC causes asystole cardiac arrest -HIGH VOLTAGE AC/DC = ASYSTOLE Dysrhythmias are common (PACs, PVCs, SVT, Afib)

What disease process is responsible for most altitude-related deaths and at what point does usually occur?

-High-Altitude Pulmonary Edema -Most commonly on the second night at altitude -Most patients also have acute mountain sickness -Fever / rales / pink sputum Normal heart size -NON-CARDIOGENIC heart failure -Severe hypoxemia and respiratory alkalosis

What post MI complication do you need a pacemaker?

-High-grade blocks (i.e. Mobitz II, 3° AV block) seen in anterior MI due to structural loss of conduction tissue

What are the injury patterns from the 3 main vectors leading to traumatic pelvic injuries? (High speed MVA, Fall from height, Blow to side)

-High-speed motor vehicle collision ⇒ AP compression ⇒ Bladder injury, hematuria, dislocation of pubic symphysis, fracture of pubic bones, also disrupt the posterior sacrospinous ligaments causing "open book" fracture. -Fall from height ⇒ Vertical shear ⇒ Sacral fracture, sacral nerve root injury -Fall from height or blow from the side ⇒ Lateral compression sacral fracture

What are signs & symptoms of laryngotracheal injury?

-Hoarseness -Subcutaneous emphysema -Sore throat -Stridor -Painful swallowing

What is one of the top five leading causes of death in females <35 y/o?

-Homicide -Nearly half of IPV homicide victims visited a health care provider within 1 year of their deaths

What is treatment for necrotizing external otitis?

-Hospitalization -IV antibiotics -ENT consultation.

What is an effective treatment for stingray envenomation?

-Hot water immersion -Stingray venom is heat labile

What is the most common household alkali, and what type of injury occurs if ingested in small amounts?

-Household bleach -Rarely causes significant injury if ingested in small amounts.

What current kills you? What is household current?

-Household current is 15-30 Amps -"Let go" current: 3-5 mA children, 6-9 mA adults -Tetany occurs at 16-20mA, Vfib at 5-100 mA

Of these 3 mammalian Bites, dog,cat & human. Which ones have the highest and lowest rate of infection, and what is tx for all of them?

-Human = highest - Dog = lowest -Augmentin txs all.

What is treatment of Sickle Cell Crisis?

-Hydration -Analgesics -O2 -Transfusions if indicated -Emergent exchange transfusion for serious sickle crisis (CNS infarction, sequestration) -Antibiotics if indicated

Is hydrocephalus ex vacuo a neurosurgical emergency? Why or why not? Patient presents with confusion, ataxia, and urinary incontinence. CT scan shows enlarged ventricles. What is DX? LP shows normal opening pressures. This is the one treatable form of dementia.

-Hydrocephalus ex vacuo Passive enlargement of ventricles due to severe cerebral atrophy- just bad atrophy -Normal pressure hydrocephalus Clinically misdiagnosed as Alzheimer's or Parkinsonism Treatable cause of dementia- the ONE TREATABLE FORM OF DEMENTIA!!! -Caused by a chronic communicating form of hydrocephalus -Classic triad: progressive dementia, ataxia (leg symptoms are early), urinary incontinence ("wet, weird, and wobbly") CT: Enlarged ventricles, no atrophy -LP: Opening pressure not elevated (high normal) Treatment: Shunt

Household cleaning agents such as toilet bowl cleaners contain _____________________.

-Hydrochloric acid

The primary toxicity seen with topical dermal exposure to most acids is burns. What acid is the exception to this and causes systemic toxicity?

-Hydrofluoric acid -Causes hypocalcemia and hypomagnesemia after topical dermal exposures -Aggressive decontamination of the skin followed by topical application of calcium and/or magnesium preparations can help limit absorption

In patients with a history of cancer, what electrolyte abnormality should be considered with the onset of the symptoms of nausea, lethargy, and an altered mental state?

-Hypercalcemia

What electrolyte abnormalities associated with multiple myeloma?

-Hypercalcemia -Hyperuricemia -Hypokalemia -Dehydration.

What is difference in QRS in hypercalcemia vs hypocalcemia?

-Hypercalcemia - (Think hyper = fast = Short QT interval) -Hypocalcemia - (Think hypo = slow = Prolonged QT interval)

How come hyperkalemia, hypocalcemia, and hypokalemia may occur from blood transfusion? What other 2 complications may occur with transfusions?

-Hyperkalemia - from lysed RBCs -Hypocalcemia from citrate causing chelation (causes prolonged QT) -Hypokalemia from citrate -Hypothermia / fluid overload

What does HHNS stand for, and how is it different from DKA?

-Hyperosmolar Hyperglycemic Non-ketotic State -No ketoacidosis -Glucose is usually higher, often >1000 -Serum osmolality is often greater than 350 -Occurs with NIDDM -Higher mortality than DKA -DKA has shorter onset

What are the most common antecedent signs/symptoms for eclampsia?

-Hypertension -Headache (persistent frontal or occipital headaches or thunderclap headaches) -Visual disturbances (scotomata, loss of vision, blurred vision, diplopia, visual field defects,photophobia) -Right upper quadrant or epigastric pain -Ankle clonus

What are signs of the sympathomimetic toxic syndrome from cocaine use?

-Hypertension -Hyperthermia -Tachycardia -Tachypnea.

What is the most common cause of sudden cardiac death in young athletes?

-Hypertrophic cardiomyopathy

What are the hallmarks of tumor lysis syndrome (TLS)?

-Hyperuricemia -Hyperkalemia (Most life-threatening complication) -Hyperphosphatemia (Malignant cells contain large amount of phosphorous) -Hypocalcemia (large release of phosphate binds calcium) -Urate nephropathy can result & cause renal failure. -TLS Caused by the massive lysis of cancer cells from chemotherapy 12-72 hrs post treatment -Blood-based cancers acute or chronic lymphocytic or myelogenous leukemia & -Non-Hodgkins lymphoma are all prone to TLS

What condition is a pooling or layering of red blood cells in the anterior chamber of the eye resulting most commonly from trauma, such as tears or lacerations of the deep structures?

-Hyphema -Most commonly from trauma.

What 5 life-threatening causes of ataxia must you rule out?

-Hypoglycemia -Intracranial infections -Intracranial mass -Bleed -Stroke.

What are 3 complications from treatment of DKA?

-Hypoglycemia due to excess insulin (Add glucose administration when glucose = 250 mg/dl) -Hypokalemia is associated with insulin administration, bicarbonate, hydration -Cerebral edema

What is treatment for adrenal insufficiency?

-IVF - NS or D5NS -#1 treatment Glucocorticoids - hydrocortisone 100 mg or dexamethasone 4 mg IV, IF DX UNCLEAR give decadron b/c it doesn't affect ACTH cortisol test. -Pressors

What is most common electrolyte abnormality in patients with weakness, and what are the causes?

-Hypokalemia -Causes: -Decreased intake (e.g. NPO) -Increased output -Renal losses -DIURETICS, osmotic diuresis -Increased aldosterone -Magnesium deficiency -Renal tubular acidosis -GI losses: VOMITING, DIARRHEA, NG suction

What electrolyte abnormalities prolong QT interval?

-Hypokalemia -Hypocalcemia -Hypomagnesemia -Remember Prolonged QT leads to torsade de pointes, Vfib

A 15 y/o male presents with weakness after working out gym. He has h/o thyroid disorder, and earlier did eat a large meal prior to working out.He cannot stand or get out of chair because of the severe weakness. What is the DX?

-Hypokalemic periodic paralysis -Rapidly progressive extremity weakness in young Asian males -Limb paralysis after exercise or high carb meals No pain, normal sensation Associated with hypokalemia, thyrotoxicosis, steroids, alcohol, renal disease -Hypokalemic periodic paralysis -Autosomal dominant, most common,avoid high-carbohydrate, high-sodium diet -Thyrotoxicosis: Young Asian males, onset after exercise

What is most common Laboratory abnormalities in adrenal insufficiency?

-Hyponatremia = most common abnormality) +/- hyperkalemia, Other lab abnormalities: -Eosinophilia (Most common in chronic insufficiency) -hypoglycemia -Low Na+ & High K+=Adrenal insufficiency -Hyponatremia & hyperkalemia = adrenal insufficiency.

What electrolyte abnormalities occur in primary adrenal insufficiency, and how is glucose affected?

-Hyponatremia and hyperkalemia from aAldosterone deficiency -Hypoglycemia from cortisol deficiency -Have destruction of the adrenal cortex in primary adrenal insufficiency (Addison disease) so no aldosterone, no cortisol, no gonadocorticoids

Which is more common in hyperglycemic states, including diabetic ketoacidosis, hyponatremia or hypokalemia?

-Hyponatremia is more common in hyperglycemic states, including diabetic ketoacidosis.

What is treatment for hyponatremia?

-Hyponatremia that develops slowly should be corrected slowly -HYPOVOLEMIC hyponatremia -Replace fluid deficits with NS 100-150 mL/hr -HYPERVOLEMIC hyponatremia -Goal is to increase Na+ and H2O loss -Salt and water restriction -Diuretics to increase Na+ loss Caveat: May worsen hyponatremia because water leaves in excess of Na+ -Faster correction: IV NS & loop diuretics (furosemide) -EUVOLEMIC hyponatremia -Correct underlying cause Water restriction (+/- furosemide if Na+ < 120)

Hypophosphatemia may occur in DKA. What does this cause?

-Hypophosphatemia: -Failure to generate adequate ATP so = weakness -Respiratory depression, muscle weakness -CHF, decreased mental status

What are the 3 H's that increase morbidity and mortality rates in patients with TBI?

-Hypotension -Hypoxia -Hyperthermia

What are the classic signs of pericardial tamponade?

-Hypotension -Muffled heart sounds -Distended neck veins.

What are 4 things that you check for in AMS in patient on hemodialysis?

-Hypotension #1 -Hypoglycemia-Check Glucose -Hypercalcemia-Check Ca++ -Subdural hematoma-Check CT

What is most common complication of hemodialysis?

-Hypotension (most common) from taking too much fluid out.

What are common side effects of propofol?

-Hypotension and respiratory depression

What is treatment of choice in hypothermic arrest?

-Hypothermic arrest - ECMO is the treatment Resuscitation indicated for any signs of life Aggressive invasive rewarming measures Airway management (as per usual) CPR use somewhat controversial -Pulses very difficult to palpate in hypothermia Take pulse for at least 60 seconds Even if 1 pulse in 60 seconds then don't do CPR. Any organized rhythm should be assumed to be perfusing Treatment of dysrhythmias controversial

What are chronic causes of constipation?

-Hypothyroidism -Hypoparathyroidism -Lead

Does pulmonary embolism present with hypoxia and hypotension?

-Hypoxia and hypotension can be present in large pulmonary emboli, but most pulmonary emboli are small and don't cause these problems.

-if NON-MIDLINE anal fissures are present then what does this suggest?

-IBD, CA, sexual abuse

What is most important predictor of Liver dysfunction?

-INR

At what level of IOP do you consult ophthalmology?

-IOP >40 mmHg: Emergency referral -IOP 30 to 40 mmHg: Urgent referral (within 24 hours) if no symptoms suggesting acute glaucoma -IOP 23 to 24 mmHg needs repeat measurement

What is 1st line treatment for stable V. tach?

-IV antiarrhythmic agents or synchronized cardioversion

What medications can you use for afterload reduction to treat heart failure?

-IV nitroglycerin -ACE inhibitors -Nitroprusside

What is treatment of myxedema coma?

-IV thyroxine and corticosteroid.

How do you manage tet spell?

-IV, O2, Monitor -IV bolus -Knee-chest position -Morphine -Bicarb -Phenylephrine -Propranolol -Goals: 1) Correct hypoxia 2) Increase SVR (systemic venous return) 3) Increase PVR (Peripheral vascular resistance) 4) Thus decrease the magnitude of the right-to-left shunt across VSD -IVF increases RV filling and pulmonary flow. -Knee-chest increases SVR (systemic vascular resistance), which increases movement of blood from right ventricle into the pulmonary circulation rather than the aorta. (#4 goal) -Morphine - uncertain mechanism -Bicarb -treats lactic acidosis -Propranolol: relaxation of the RVOT with improved pulmonary blood flow & decrease cardiac contractility -Phenylephrine - increases SVR

What are 5 risk factors for spinal epidural abscess?

-IVDA -Chronic renal insufficiency, -Diabetes -Immunocompromised state -Recent invasive spinal procedures.

The tricuspid valve is most commonly affected by infective endocarditis in what type of patient, and what is the pathogen?

-IVDA patient -Tricuspid valve most common (50%) -Staph. aureus is the most common pathogen

What is initial therapy of sepsis?

-IVF -Antibiotics -Lowering the lactate level 10% in 2 hours.

What is 3-part tx for hypercalcemia?

-IVF SALINE - 2-4 L Dilutes calcium and increases GFR thereby increasing the calcium load excreted by the kidney -LASIX LOOP diuretics (furosemide) Facilitates calcium excretion but are advised only after hydration achieved -BISPHOSPHONATES (zoledronic acid / pamidronate) Inhibit osteoclast function and decrease bone resorption - response seen within 2-4 days, nadir at 7 days). Used once hydration has been completed

Which NSAI is effective in most cases of pericarditis and has fewer side effects than other NSAIDs?

-Ibuprofen

Since 2010 FDA has approved 4 new anticoagulant drugs - 3 factor Xa inhibitors and 1 direct thrombin inhibitor. Which of these has FDA approved a reversal agent?

-Idarucizumab (Praxbind)as a reversal agent for dabigatran (Pradaxa) -Prothrombin complex concentrate is frequently used to reverse the effects of the Xa inhibitors

What is the dabigatran specific antidote?

-Idarucizumab (pronounced "I-dare-you-cizumab": (Pradaxbind)

What is advantage and disadvantage of sodium nitroprusside?

-Ideal medication for hypertensive emergencies (rapid onset, potent, short half life) -Metabolized to thiocyanate (cyanide) therefore do not use for long in renal or pregnant pts -Can cause reflex tachycardia, therefore use with beta blocker

What are causes of primary adrenal insufficiency?

-Idiopathic (autoimmune): Addison's Disease - most common in western countries. Infiltrative, infectious Sarcoid, amyloid TB, fungal, septicemia Hemorrhage, infarction Neoplastic Drugs (etomidate) -Bilateral adrenal failure is associated with meningococcemia (Waterhouse-Friderichsen)

What is the most common cause of dilated cardiomyopathy?

-Idiopathic (most common) Other causes: -Alcohol -Peripartum -Viral (myocarditis) -End-stage CAD -Hypothyroidism

What type of peripheral vertigo is associated with hallmarks of tinnitus and hearing loss?

-Idiopathic endolymphatic hydrous AKA known as Meziere disease -Due to increased endolymph within the inner ear.

A young, obese female presents with headache and vision changes; papilledema, visual field defect, or an enlarged blind spot. What is the diagnosis?

-Idiopathic intracranial hypertension -Assoc. with use of oral contraceptive medications, tetracycline, anabolic steroids, and vitamin A. -Confirmed with elevated CSF opening pressures (>20 mm Hg) with a normal CSF analysis. Tx: Intermittent CSF drainage and acetazolamide.

What is the most common pediatric platelet disorder?

-Idiopathic thrombocytopenic purpura (ITP)

What is Legg-Calve-Perthes disease, and how does it differ from SCFE?

-Idopathci avascular necrosis disorder of femora head. -2 factors distinguish it from SCFE. 1) Gradual onset 2) Younger kids 4 to 8 years old,

In patients who suffer a nonfatal drowning who may be discharged home?

-If have good oxygenation, scattered rales then can discharge. -All others should be admitted

Refractory Anaphylaxis

-If no cardiovascular collapse then repeat intramuscular epi -if cardiovascular collapse (hypotension & tachycardia) then give IV bolus 0.1 mg of 1:10,000 epi Over 5-10 minutes followed by infusion

Under what situation do ingested batteries not need to be removed?

-If passed esophagus & asymptomatic -If passed the pylorus within 48 hours -Most will pass completely in 48-72 hours -Asymptomatic batteries in the stomach are followed by serial X-rays -Treatment if in esophagus: Immediate GI consult broad-spectrum antibiotics

When can patient with traumatic hyphema be safely discharged for outpatient management without a consultation from ophthalmology?

-If the hyphema is small and if the patient has no risk factors for complications.

What is role of prophylactic endotracheal intubation in pulmonary contusion?

-If the patient is alert, noninvasive positive pressure ventilation is preferred treatment for oxygenation. -Prophylactic endotracheal intubation is unnecessary

In what setting would you use inotropes to treat heart failure?

-If very low EF or acute MI + AHF in presence of borderline BP - Use Dobutamine

How does urticaria occur?

-IgE MEDIATED → mast cells → histamine release -Diffuse pruritus, wheals, hives (superficial dermis) -Etiology is unknown most of time Usually self-limited TX: Antihistamines, steroids, antipruritics, H2 blockers, epinephrine

Who do you need to immediately consult if you think patient has bacterial tracheitis?

-Immediate ENT consultation.

A HIV patient is started on antiretroviral therapy (ART) and preexisting infectious processes start worsening. What is the diagnosis? How do you tx this?

-Immune Reconstitution Syndrome or "immune reconstitution inflammatory syndrome" (IRIS) -Paradoxical worsening of preexisting infectious processes following the initiation of antiretroviral therapy (ART) in HIV-infected individuals -Continue antiretroviral therapy. -TX underlying opportunistic infection. -Steroids -Most commonly with: -Subclinical TB -Cryptococcal meningitis (fungus) -CMV (herpes family) -Hep C

What do you do if you see an umbilical Cord Prolapse?

-Impede delivery and elevate presenting part -Knee-to-chest position -Immediate C-section -High perinatal mortality

In what type of patients is there increased frequency of perforation in appendicitis?

-In elderly and small children

How does Pemphigus vulgaris (PV) present?

-In middle-aged to older-aged patients -Autoimmune vesiculobullous disease that frequently causes oral lesions then progresses to skin blisters. -Often start in mouth -Oral lesions antedate the cutaneous lesions by several months. -Primary lesion of PV is flaccid, clear blister that becomes fragile and erupts, producing erosions. -Pressure applied to these blisters/bullae results in sloughing, known as a +Nikolsky sign.

What are the middle causes of widened mediastinum?

-In order by decreasing occurrence: -Lymphadenopathy secondary to lymphoma -Sarcoid, then -Metastatic lung cancer.

When should placental abruption be considered in pregnant woman?

-In pregnant women with acute abdominal or uterine pain with or without bleeding.

What is a TIA VS ischemic stroke?

-In the tissue-based definition, TIA is a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, WITHOUT acute infarction. -Ischemic stroke is defined as an infarction of central nervous system tissue (brain, spinal cord, or retinal cell death) attributable to ischemia, based on neuropathologic, neuroimaging, and/or clinical evidence of permanent injury. -Benign connotation of "TIA" has been replaced by an understanding that even relatively brief ischemia can cause permanent brain injury.

What is phimosis?

-Inability to retract the foreskin back from covering the penis.

What is paraphimosis?

-Inability to return the retracted foreskin to its natural anatomic position.

-Syndrome of Inappropriate Secretion of Antidiuretic Hormone - SIADH - What are the causes of this?

-Inappropriate ADH secretion (inhibits urine production resulting in fluid retention and dilutional hyponatremia) so YOU DON'T PEE & body Holds onto H2O by holding onto Na+ -Inappropriately concentrated urine in the setting of low serum osmolality (low sodium) and normovolemia = SIADH -Causes: -CNS (tumor, infection, CVA, injury) -Lung (infection including TB, fungal) -Drugs (chlorpropamide, vasopressin, diuretics, Chemo Rx's :vincristine &cyclophosphamide, antipsychotic: thioridazine)

What is difference between incarcerated and strangulated hernia? Do you reduce a strangulated hernia? Why or why not?

-Incarcerated: irreducible (bowel obstruction is common) -Strangulated: irreducible with vascular compromise and ischemic bowel (do not manually reduce)

How does the incidence of lower tract disease in HIV-positive patients correlate with the CD4 count?

-Incidence of lower tract disease increases as the CD4 count decreases.

Isopropanol ingestion can cause coma, but the presentation includes ___________, not ____________.

-Includes a ketosis, not acidosis. -Isopropanol (isopropyl alcohol), typically referred to as rubbing alcohol, is converted by alcohol dehydrogenase to acetone, a ketone (not a ketoacid).

What is classic ECG findings of Brigade syndrome?

-Incomplete right bundle branch block and ST-segment elevation of V1 and V2.

What are the differences in vascular injuries between injury vectors that increase pelvic volume vs decrease pelvic volume?

-Increase pelvic volume = increased vascular injury. -Injury vectors that increase pelvic volume are much more likely to injure pelvic vessels due to stretching forces on the vessels. -Compressive forces leading to decreased volume of the pelvis are less likely to cause significant bleeding.

What are 6 risk factors for asthma-related death?

-Increased use of beta agonists -Poor self-perception or physician perception of a patient's asthma -Lack of following formal care plan -Illicit drug use -Severe asthma -Sensitization to mold

Why are PPI's recommended for patients with nonvariceal bleeding from peptic ulcers?

-Increasing gastric pH allows for clot formation. -Reduces the rate of rebleeding -Reduces the need for surgical intervention -Decreases need for blood transfusion -Hospital length of stay.

When is rabies postexposure prophylaxis (PEP) indicated?

-Indicated for individuals who are bitten or experience other mucous membrane exposure to high risk animals. -High risk animals in US: -Bats -Foxes -Raccoons -Skunks.

-Impactions that prevent handling of secretions -Ingestion of sharp objects or button batteries -Impaction in the esophagus for > 12 to 24 hours.

-Indications for immediate endoscopy in esophageal food impaction

What is difference between indirect and direct inguinal hernias?

-Indirect inguinal: herniates through inguinal canal, extends into scrotal sac. Common in boys -Direct inguinal: herniates through abdominal wall. Common in middle age men

What is the most effective diagnostic test for fulminant myocarditis?

-Indium contrast-enhanced cardiac MRI.

What is the appropriate interspace levels for lumbar puncture in an infants, adults and children?

-Infant: L4-L5 and L5-S1. -Adults and children: L2-L3 and below.

What are absolute contraindications for ketamine?

-Infants <3 months of age -Known or suspected schizophrenia

What is the leading cause of death in sicklers, especially in <5 y/o? Why are they prone to this?

-Infection -Prone to infection by encapsulated organisms b/c are functionally asplenic so predisposed to these types of infections . -Pneumococcus -Salmonella (bone infection), -H. influenzar -Staph -E. coli -Mycoplasma -Also watch for influenza and parvovirus

What is most common precipitant of Aplastic crisis?

-Infection (parvovirus)

In a renal transplant patient with infection any rise in creatinine may indicate what? Who do you consult?

-Infection and Rejection -Can be subtle clinically Any rise in creatinine is cause for alarm -Consult transplant team

What is the most common cause of acute DIC?

-Infection. Other causes: -Meningococcemia (most extreme form of DIC), -Trauma (especially head) -Sepsis -Retained products of conception

How do you treat thyroid storm?

-Infections are common cause, so low threshold for broad-spectrum abx -Physiologic stressors may cause it. Surgery, childbirth, infection. -5 STEPS to treat: In following order: 1)SUPPORTIVE CARE: IVF, CORTICOSTEROIDS (decadron or hydrocortisone) decreases T4-to-T3 conversion, promote vasomotor stability, and possibly treat an associated relative adrenal insufficiency [NO ASA (displaces thyroid hormone from thyroglobulin)] 2) BLOCK PERIPHERAL EFFECTS thyroid hormone effectsBeta-blockers (Propranolol) to control the sx's and signs induced by increased adrenergic tone, also blocks conversion T4-T3) 3) BLOCK NEW HORMONE SYNTHESIS- Thionamide (Propulthiouracil[PTU] or methimazole) 4) BLOCK RELEASE OF THYROID HORMONE- 1 hr after thionamide (PTU) give iodine 5) IDENTIFY and TREAT PRECIPITATING EVENTS

What causes erythema nodosum?

-Infections: TB, strep, URIs. -Inflammatory processes: Sarcoidosis -Autoimmune disorders. -Medications: phenytoin, penicillin, oral contraceptives, and sulfonamides. -Many times, the cause is never determined.

What is standard of care for initial management of hemothorax in penetrating trauma?

-Initial intervention: Place a large-bore (32 French) thoracotomy tube in the fifth intercostal space at the anterior axillary line on the affected side -Massive or persistent hemothoraces (>1,500 mL of initial tube output or continued output of >200 mL/hr in the first several hours) should prompt consideration of surgical thoracotomy.

What is the most efficient test to rapidly make a diagnosis of TB?

-Interferon-gamma release assay (QuantiFERON-Gold Plus).

-Purified protein derivative (PPD) skin test is one reliable approach to assessing TB status. The test, which works through a delayed (or type IV) hypersensitivity reaction, is interpreted for positivity within 48 to 72 hours based on the size of the reaction. What is an alternative TB test?

-Interferon-gamma release assay (known commercially as QuantiFERON-TB), which evaluates for cell-mediated immune activity against Mycobacterium tuberculosis.

What can you do for internal exposure?

-Internal decontamination GI decontamination -Activated charcoal and whole bowel irrigation -Potassium iodide for I-131 ingestion

What causes Cauda equine syndrome?

-Intervertebral disc herniation, epidural abscess, tumors at L4-5. -Compression of peripheral nerve roots S2-S5 -Lower motor neuron lesion -Motor and sensory loss -GRADUAL ONSET -Hyporeflexia, saddle anesthesia -Urinary retention and overflow incontinence -Decreased anal tone, fecal incontinence -Neurosurgical emergency,

What GI complication is associated with HSP, and presents with the symptoms of episodic pain associated with increased sleepiness?

-Intussusception

What illnesses are associated with Henoch-Schönlein purpura?

-Intussusception and renal disease.

How do you differentiate between the following: -Intussusception -Internal hemorrhoids -Rectal prolapse

-Intussusception: can place finger between protruding rectum and anus -Internal hemorrhoids: fold of mucosa radiates out like spoke on a wheel -Rectal prolapse: folds of mucosa are circular

What is disseminated zoster, and what is concerning issue with this?

-Involvement of three or more dermatomes. -Should raise the question of an underlying immunocompromised state, perhaps HIV/AIDS, lymphoproliferative disorder, chronic immunosuppressant therapy, or organ transplant. -Herpes zoster is the reactivation of the dormant varicella-zoster virus that causes a painful vesicular rash in a dermatomal distribution. -Involves one dermatome and is unilateral.

What is treatment for dry socket?

-Irrigation of the socket with chlorhexidine 0.12% oral rinse or warmed normal saline. -Refer back to their dentists for follow-up care.

Atropine is key to management of OP poisoning, and is an anti-_______, but not an anti-_______. Why is this difference important?

-Is anti-muscarinic not anti-nicotinic. -Atropine is a purely antimuscarinic drug that antagonizes excessive acetylcholine at muscarinic receptors in OP poisoning. -This relieves: -Bronchospasm -Bronchorrhea -Bradycardia -Importantly, atropine does not reverse respiratory paralysis that occurs as a result of excess acetylcholine at nicotinic receptors. -Pralidoxime treats the nicotinic effects.

What to look for on the ECG post-syncope?

-Ischemia -Dysrhythmias -Intervals (long QT, short PR → WPW) -Brugada syndrome -Hypertrophic cardiomyopathy

What is appropriate pharmacotherapy for patients with documented latent TB?

-Isoniazid

Why does retropharyngeal abscess occur in patients < 4 y/o?

-It an infection of the paramedian lymph tissue, but it atrophies as the child develops; this is why RPA is less likely in an older child. RPA is typical in patients < 4 y/o, and peritonsillar abscess is more likely in older pediatric patients and adults.

Can necrotizing enterocolitis develop in preterm or full-term neonates?

-It can develop in both usually within the first 2 weeks of life.

Is mandatory surgical exploration of Zone II penetrating neck wounds recommended?

-It is no longer universally recommended. -Hard signs of vascular injury that require surgical intervention: -Active pulsatile bleeding -Expanding hematomas -Focal neurologic deficits. -With occult or minor or "soft" findings: -Nonexpanding hematoma -Minor change in voice -Pain -In a stable patient, CT angiography is a highly accurate test to diagnose: -Injuries to the carotid arteries -Injuries to underlying structures -Visualize trajectory of the wound.

How does acetazolamide prevent and treating AMS?

-It's a carbonic anhydrase inhibitor. It causes a bicarbonate diuresis resulting in a non-anion gap metabolic acidosis. -To maintain serum pH, the body increases ventilation to decrease Pco2, and as a result serum Po2 is increased. -Etiology of AMS is principally hypoxia.

Why can patients easily overlook the primary manifestation of primary syphilis that develops 2-4 weeks after exposure? What lab test must you do to check for primary syphilis (Treponema palladium)? What test May Be Negative in Early Primary Syphilis?

-It's a painless genital lesion. -Think painless chancre lesion of penis = Primary syphilis -Wherever I touch it that's where I get the lesion. If I get it while in Vegas on 7.26.17, I will get Chancroid around board exam time. It'll be painless and whereever I contacted it (lip, penis, tongue etc) LAB: DARKFIELD microscopy must do this for primary syphilis -VDRL & RPR(Nontreponemal test)= initial screening - detect nonspecific treponemal antibodies -Follow VDRL/RPR titers to see if tx working ****Serology (VDRL / RPR) May Be Negative In Early Primary Syphilis -FTA-ABS or MHA-TP= (Treponema test -Fluorescent treponemal antibody absorption) - Confirmatory test -Most sensitive/specific ***On board if question asks to check RPR choose RPR

What are the causes of non-gap Acidosis?

-It's renal or GI etiologies. -HARDUP -Hypoaldosteronism -Acetazolamide -Renal tubular acidosis -Diarrhea -Ureterosigmoidostomy -Pancreatic fistula

What is a characteristic of osteoarthritis?

-Joint pain that gets worse with activity and better with rest.

What is treatment for dilated cardiomyopathy?

-Just treat symptomatically.

What is most common cause of blood in stool in lower GI Bleeding in Adults?

-Upper GI Bleeding

Eaton-Lambert is similar to M. Gravis. What are 2 differences?

-Lambert-Eaton Syndrome 2 Differences from M. GRavis: a) Associated with h/o cancer like small cell lung CA b) weakness IMPROVES WITH USE -Clinically similar to myasthenia gravis -Autoimmune, affects calcium channels (muscle function) See decreased DTRs -Remote effect of cancer (in 50%) on the nervous system (esp. small cell lung CA), Has h/o Cancer in board question. -Failure of release of acetylcholine from terminal presynaptic axons of motor neurons by calcium channel antibodies -Weakness and fatigue of proximal muscles, especially thighs and hips (weakness IMPROVES WITH USE) -Treatment: Remove tumor, plasmapheresis If possible avoid neuromuscular blocking agents, aminoglycosides, IV contrast, calcium channel blockers (all may cause worsening weakness)

Which type of perforations are more common large bowel perforations or small bowel perforations? What is the best xr view to detect free air from bowel perforation? What is the most common overall cause of visceral perforation?

-Large bowel perforations are more common than small bowel perforations -X-rays may miss small amounts of free air or retroperitoneal air. Best view is upright CXR or left lateral decub if unable to stand Ulcers are the most common overall cause of visceral perforation.

Blunt trauma causes______________ defects in the diaphragm than penetrating trauma does.

-Larger

What are sided effects of ketamine?

-Laryngospasm -Agitation -N/V -Might increase ICP/IOP

What syndrome presents with ataxia, n/v, and loss of pain and temperature sensation in the ipsilateral face and the contralateral trunk and limbs and -Ipsilateral findings: -Facial numbness -Decreased pain and temperature sensation -Paralysis of the soft palate or pharynx -Horner syndrome (Ptosis, miosis, anhydrosis) -Corneal reflex loss -Contralateral: -Loss of pain and temperature sensation in the limbs and trunk

-Lateral medullary infarction of the brainstem, also known as Wallenberg syndrome -Vertebral artery thrombosis

How does gastric lavage affect mortality or transfusion requirement in UGIB?

-Lavage - no decrease in mortality or transfusion requirements, -Clear aspirate may miss up to 15% of lesions

What is profile of Malignant Melanoma?

-Least common but most lethal Ages 30-50 -Risk factors: Adulthood, dysplastic nevi, family history of melanoma, fair skin, UV exposure, congenital nevi -Account for majority of skin cancer deaths -Sun exposed areas (head, neck, trunk) -The greater the depth, the worse the prognosis -Metastases are common, irregular border

What is difference between Left sided IE vs Right sided IE?

-Left sided IE: Mitral valve S. VIRIDANS, S. aureus Gram NEGATIVES (IVDA or contaminated catheters) -Cause of death = heart failure -Emboli most common complication: CNS & systemic infarction Right sided IE: Tricuspid -IVDA, indwelling catheters -STAPH aureus, S. pneumoniae, gram negatives -Emboli most common complication: PULMONARY infarction & infection -Less heart failure, Lower mortality rate

What is the most common cause of right sided failure?

-Left sided failure

What is the most common pelvic tumor, and what race is this most common in? How do you dx it? What is TX?

-Leiomyomas (Fibroids) -Benign tumors of uterine muscle -Most common pelvic tumor; -Most common in African American women Pelvic pain, abnormal bleeding, anemia Pregnancy can result in rapid growth and loss of blood supply (degeneration) -Diagnosis: Ultrasound -Treatment: NSAIDs,hormonal therapy, surgery

What are the primary determinants of risk for decompression sickness? What are the 2 types of decompression sickness?

-Length & depth of dive -Type I and Type II decompression sickness. (II is more serious) Type I = Musculoskeletal, skin, lymphatics Type II = Any kind of neurol finding after diving -TX: Recompression in a chamber -ANY TX of diving is hyperbaric chamber

Patient worked on a farm with livestock in Hawaii presents with hepatitis, nephritis, meningitis, and coagulopathy. What is the diagnosis, and how do you treat it?

-Leptospirosis - spirochete, Half cases in Hawaii -From infected Rats, cattle, pigs, dogs Skin contact with urine of infected animal & Contaminated water Hepatitis, nephritis, meningitis, coagulopathy Weil's disease (severe form): Jaundice, subconjunctival hemorrhage, hepatitis, DIC -Death from hepatorenal failure -Tx: Pen G, tetracycline, doxycycline

If a neck mass can be moved around and compressed, it's less likely or more likely to be malignant?

-Less likely to be malignant - those features are more consistent with a cyst.

What is toxic epidermal necrolysis (TEN)?

-Life-threatening dermatologic condition. -Diffuse erythematous macular rash that coalesces, resulting in regions of skin with the epidermis separating from the dermis. -Mucosal involvement and +Nikolsky sign. -Different from PV in that PV starts with individual blisters without the typically large erythematous coalescing areas as seen with TEN. -First affect the eyes, then spread caudal to the thorax and upper extremities, and finally progress to the lower body. -Most commonly drug induced (sulfa, PCN, ASA, NSAIDs). -Also associated with (infection, malignancy, vaccines). -Persons with AIDS who are on sulfa prophylaxis are 1,000 times more at risk of developing TEN. -Treatment: Admission to ICU or burn unit for fluids and electrolytes, control of pain and infection, and stopping offending agent. -No specific therapy proven effective. -Mortality rate high secondary to sepsis and MOSF.

What is descending necrotizing mediastinitis?

-Life-threatening surgical emergency that often follows an odontogenic infection or thoracic instrumentation. -First priority in emergency department management is IV broad-spectrum antibiotics intravenously. -Requires immediate surgical consultation and intervention.

How does neurocognitive disorder with Lewy bodies present?

-Like other neurocognitive disorders have problems with executive function and attention. -DISTINCTION: -visual hallucinations -sleep disorder -Parkinsonism. -Has cognitive fluctuations, but no underlying cause is identified. -Develops in mid-70s -2nd most common type of dementia after Alzheimer disease.

What type of necrosis occurs with caustic alkali injuries?

-Liquefaction necrosis

What sort of bleeding occurs with von Willebrand disease?

-Mucosal and cutaneous bleeding are common in von Willebrand disease, typically GI bleeding and menorrhagia.

Strokes of the anterior cerebral artery: -Loss of __________ lobe function (lack of judgment or insight into their conditions) -Weakness, sensory findings _______________ to the lesion -Lower extremities affected _____________ than upper extremities and face.

-Loss of FRONTAL lobe function -Weakness, sensory findings CONTRALATERAL to the lesion -Lower extremities affected > than upper extremities and face.

What are the lab findings in hypothyroidism?

-Low T4, HighTSH (unless problem with hypothalamus or pituitary) -Elevated lipids, so slow and sluggish your cholesterol goes up

What is mortality rate and rate of major intrathoracic trauma associated with Sternal fractures?

-Low mortality rate. -Low rate of associated major intrathoracic trauma

What decreases the risk of ventilator injury to the lungs in patients with ARDS?

-Low tidal volume (6 mL/kg initially) mechanical ventilation -Positive end-expiratory pressure -High-frequency oscillatory ventilation -Prone positioning ventilation

What is considered low voltage injury?

-Low voltage injury: <1000 V -More common (greater access) -Half of all injuries and deaths -Burns tend to be minor (110 V) -Half of low voltage deaths have NO BURNS -Low voltage AC causes cardiac arrest, usually V. FIB LOW VOLTAGE AC = V. FIB Other arrhythmias rare with 110 V

Patients with a high body mass index tend to have _______ levels of BNP

-Lower

What are benefits of Observation units?

-Lower health care costs -Improve patient safety and satisfaction -Shorten hospital length of stay. -Improve diagnostic accuracy and therapeutic outcomes

What is bronchiolitis?

-Lower respiratory tract infection -most commonly in children < 2 y/o. -Caused by RSV. -Nasal congestion, cough, and wheezing. -Occurs during the winter -Do not present with stridor or lethargy -American Academy of Pediatrics defines bronchiolitis: -Child younger than 24 months. -Rhinitis -Tachypnea -Wheezing -Cough -Crackles -Accessory muscle use -Nasal flaring

What is the most common cause of lumbar radiculopathy, or sciatica, a shooting or burning pain from the low back radiating down the posterior leg distal to the knee?

-Lumbar disc herniation, and the most common of these is an L5-S1 herniation.

Patient presents with painless herpes-like ulcerate bubo in groin. What is organism, diagnosis & TX? What specific sign do you see in the bubo? What do you avoid in treatment?

-Lymphogranuloma venereum (LGV) -Chlamydia trachomatis -Primary lesion: painless herpes-like ulcer -Inguinal "buboes" (enlarged nodes), -GROOVE sign - -DON'T I&D -Labs: Nucleic acid amplification technique (NAAT) such as the polymerase chain reaction (PCR) assay. TX: doxycycline x 3 weeks

What are the most common cancers that metastasize to the testes?

-Lymphoma -Leukemia -Lung cancer

What is most common cause of pneumonia in school-aged children?

-M. pneumoniae

What is most common valvular involvement for infective endocarditis?

-MATP Mnemonic -Mitral #1 > aortic > tricuspid (IVDA) > pulmonic

What is difference between heat stress, heat exhaustion, and heat stroke?

-MINOR: Heat stress: (NORMAL CORE TEMP) feel hot & strained with exposure to a hot environment, especially during physical work -Na+ losses (local) -Elevation (not diuretics) -Vasodilation & Blocked sweat gland MODERATE: Heat exhaustion: (SLIGHT ELEVATION of core temp, <40˚C) -Mild-to-moderate illness due to water or salt depletion -Exposure to high heat or strenuous physical exercise -Think Summer Flu -Thirst / weakness / anxiety / dizziness / lightheaded, HA, -N / V / D, water depletion, salt depletion -SEVERE: Heat stroke: (core > 40˚C): -Hyperthermia associated with (SIRS) and multi-organ dysfunction with encephalopathy (AMS) -CNS changes, liver "meltdown" Heat stroke = MOSF + AMS

What is imaging modality of choice to diagnoses spinal epidural abscess?

-MRI

What are advantages of LMWH over unfractionated heparin?

-MUCH Less likely to cause thrombocytopenia -Reliable dose/response curve = no monitoring Does not affect the aPTT - why? -- LMWH primarily affects factor Xa (the aPTT is relatively insensitve to factor Xa) but is sensitive to thrombin which is the primary target of UFH Unfractionated heparin affects Factor Xa & Thrombin. LMWH affects only Factor Xa. -aPTT is not sensitive to Factor Xa, but it is only sensitive to Thrombin. -FACTOR Xa is a component of the FINAL COMMON PATHWAY of the clotting cascade

What are first-line treatment for pertussis infections, and what is primary goal of treatment?

-Macrolides -Primary goal of antibiotic therapy in pertussis is to reduce infectivity, not the duration of symptoms.

How do you tx regional Adenopathy of Cat Scratch Fever?

-Macule at the site of the bite or scratch Regional lymphadenopathy draining the site of the injury -Caused by dogs, cats, monkeys -Organism Bartonella henselae -Antibiotics NOT INDICATED / SELF-LIMITING disease -DON'T I & D or other trauma to nodes (fistulas tracks may result)

How do you treat Torsade de Pointes, and what do you avoid?

-Magnesium (will shorten QT interval) -Overdrive pacing -Isoproterenol -Cardioversion/defibrillation -Magnesium infusion for prophylaxis after conversion -DO NOT use procainamide or amiodarone!

What is the anticonvulsive drug of choice for eclampsia, and how do you administer it? How do you tx HTN in eclampsia? What is definitive tx in eclampsia if patient is pregnant?

-Magnesium sulfate. -Initial treatment is magnesium sulfate, 4 to 6 g IV followed by infusion at 1 to 2 g/hr. -If the patient has signs of renal insufficiency, the dose should be decreased. Tx: -Treat DBP >105 (hydralazine, labetalol) MgSO4 / benzodiazepines for seizures -Definitive: Delivery -Monitor for hypermagnesemia ↓ reflexes, ↓ respiration -Treatment: Calcium gluconate

What is the mainstay of emergency therapy for pulmonary hypertension?

-Maintaining high right ventricular filling pressures by ensuring adequate intravascular volume status -IV hydration with normal saline is recommended.

For what procedures do you require antibiotic prophylaxis for IE?

-Major dental procedures only -NOT for GU/GIs procedure: No prophylaxis required

There is no role for BiPAP in this patient with ___________.

-Upper airway stridor.

What is role of colchicine in treatment of pericarditis?

-Majority of patients have resolution of symptoms without recurrent pericarditis when treated with NSAIDS alone. -However, Colchicine, when used as an adjunct to NSAID therapy, reduces symptoms, decreases the rate of recurrent pericarditis, and is generally well tolerated. -As such, we recommend that colchicine be added to NSAIDs in the management of a first episode of acute pericarditis

What type of incisions do you make when performing a perimortem cesarean delivery?

-Make vertical skin and uterine incisions when performing a perimortem cesarean delivery.

Why does a nondepolarizing paralytic agent fail to reverse the associated muscle rigidity with malignant hyperthermia?

-Malignant hyperthermia manifests with muscle rigidity that won't respond to paralytic agents.

What is difference between Mallory-Weiss tear and Boerhaave's syndrome?

-Mallory-Weiss tear (PARTIAL thickness tear) submucosal tear -Location: GE junction -Common cause of upper GI bleeding -Vomiting, retching -Risk factors: EtOH, hiatal hernia -Spontaneous resolution is common -Boerhaave's syndrome (FULL-thickness tear) = Esophageal RUPTURE -Males, ages 40-60 -Associated with vomiting -Left posterior distal rupture -Mediastinitis (first chemical, then infectious) -Severe chest pain, shock, sepsis (antibiotics) -Air in mediastinum (Hamman's crunch) -Pyopneumothorax -Gastrografin (water-soluble) UGI, CT -X-ray: mediastinal air, left pleural effusion, pneumothorax, widened mediastinum, SQ air

How do you manage sternal fractures?

-Managed conservatively with pain control.

What is recommended to control increased ICP in patients with acute traumatic brain injury?

-Mannitol

What are the causes for nephrotic syndrome?

-Many causes ranging from primary renal disease to infection to medication side effects.

What diagnosis is supported if the patient has a fever or pain with palpation over the mastoid process or posterior ear pain, and what test supports this diagnosis?

-Mastoiditis -Further supported with CT -Tx with admission & IV antibiotics.

When should you perform perimortem cesarean delivery?

-Maternal cardiac arrest at greater than 24 weeks' gestation.

In Trauma in Pregnancy what is the most important factor in determining fetal survival? What do you administer to mother if she has abdominal trauma and is Rh (-)? What imaging study do you avoid in trauma in pregancy? When do you need to do fetal monitor, and for how long? What is considered sign of abruption? If pregnant patient in trauma is hypotensive what do you do in addition to giving IVF bolus?

-Maternal stabilization -RhoGAM if Rh negative and abdominal trauma No radiologic test should be withheld if needed for maternal evaluation -Fetal monitoring >20 weeks Minimum of 4 hours Signs of fetal distress >8 contractions/hr suggest abruption Kleihauer-Betke test (controversial) For hypotension: Turn on left side (displace uterus off IVC), fluid bolus

When patient has bleeding and is on a direct anticoagulant (either direct thrombin inhibitor or Factor Xa inhibitor) why is it important to know when last dose was taken? How long does it take for normal clotting to occur when stopping direct anticoagulants?

-Maximum effect on coagulation tests occurs about 3 hours after ingestion - therefore important to know when the drug was taken. -TIME is the MOST IMPORTANT ANTIDOTE in the setting of non-life-threatening bleeding due to short elimination half- lives of these drugs -Normalization of hemostasis = 12-24 hours with the Xa inhibitors and the direct thrombin inhibitors ( with normal renal function in DTI patients) (consider dialysis with DTIs

What are risks associated with flying after diving? What rules do you follow to prevent decompression sickness after diving with regards to flying? What are guidelines for flying after treatment of DCS type 1 and DCS type II?

-May result in new symptoms of decompression sickness for divers without any symptoms initially Is why diving discouraged for 24 hours prior to flying -No flying for 3-7 days post-treatment of DCS-1 -No flying for 1 month post-treatment of DCS-2

What is role of vancomycin in treatment of infant botulism?

-May treat wound botulism, although penicillin is preferred first-line agent. -No role in the treatment of infant botulism

What pediatric disease presents with cough, coryza, conjunctivitis, and small white to blue spots ("Grains of salt") on a red base seen in the buccal mucosa, and with a rash that begins on the face; the spots rapidly blend into each other then spread down the body?

-Measles (rubeola) -The real measles -Think Fever and 3 C's -Think Koplik spots and spreads head to toe with confluence.

How do you diagnose adrenal insufficiency with the corticotropin stimulation test?

-Measure serum cortisol immediately before and 30 and 60 minutes after intravenous (IV) or intramuscular (IM) injection of 250 mcg (85 nmol, or 40 international units) of cosyntropin (ACTH) ●If the patient has hypopituitarism with deficient ACTH secretion and SECONDARY adrenal insufficiency, then the normal adrenal gland should respond to maximally stimulating concentrations of exogenous ACTH if given for a long enough time. The response may be less than in normal subjects and initially sluggish due to adrenal atrophy resulting from chronically low stimulation by endogenous ACTH. ●If, on the other hand, the patient has PRIMARY adrenal insufficiency, endogenous ACTH secretion is already elevated and there should be little or no adrenal response to exogenous ACTH.

What is focus of medical treatment of aortic dissection?

-Medical treatment focused on 2 aspects: 1) Decreasing blood pressure 2) Decreasing heart rate. -Lowering the heart rate decreases shear force on the aorta. -Beta-blockers are used for treatment for aortic dissection.

When you treat ectopic pregnancy with medical management with methotrexate what is criteria? What is the most common side effect of this treatment? And what do you assume if this side effect occurs? What is failure rate of methotrexate?

-Medical: Methotrexate Inhibits cell division in rapidly dividing fetal cells -Tubal mass < 4 cm and no fetal cardiac activity -Abdominal pain most common side effect -Presume ruptured ectopic as opposed to treatment side effect -Significant failure rate (up to 36%)

How can you distinguish pemphigus vulgaris from toxic epidermal necrolysis?

-Pemphigus vulgaris starts with individual blisters and doesn't have large erythematous coalescing areas. -TEN has large sheets of skin sloughing off.

What is best choice of blood transfusion for Men and postmenopausal women vs woman who can bear children?

-Men and postmenopausal women should receive O-positive red blood cells. -Any woman who can bear children should receive O-negative red blood cells if transfusion is needed. -Men may receive either O-negative or O-positive blood, but most experts recommend transfusing O-positive blood in order to save the limited supply of O-negative blood for female transfusion patients.

What is the Mental status exam: OMIHAT?

-Mental status exam: OMIHAT -Orientation -Memory -Intellect -Hallucinations -Affect -Thought

What is methotrexate is known to cause, and does it increase risk of infection?

-Methotrexate is a RA medication. -Causes: -Flulike illnesses -Pulmonary compromise -Renal or hepatic impairment. -DOES NOT increase the risk of infection in RA patients.

What is the antidote for patients with methemoglobinemia?

-Methylene blue is the antidote for patients who are blue (cyanotic) from methemoglobinemia. -Methylene blue is converted (via a G6PD pathway) to leukomethylene blue, that converts methemoglobin back to hemoglobin. -Methemoglobinemia occurs when the ferrous (Fe+2) form of iron in hemoglobin is oxidized to the ferric (Fe+3) form. This form cannot transport oxygen, and there is also a shift in the oxygen dissociation curve that results in an increased affinity of bound oxygen to hemoglobin.

What are among the appropriate therapies for giardiasis?

-Metronidazole -Tinidazole -Nitazoxanide

What is treatment of Giardia infection?

-Metronidazole 500 TID 10 days. -Alternatives: single-dose Tinidazole 2 g PO -Furazolidone 100 mg PO once a day 10 days.

What is most critical item in the differential diagnosis of patients presenting with unilateral facial paralysis, and how do you differentiate this from idiopathic facial paralysis?

-Middle cerebral artery stroke -With stroke patient has sparing of the forehead muscles and can raise the eyebrow on the affected side -Contralateral paralysis, arms and face -Sensory deficit (same distribution) -Aphasia (if dominant hemisphere) or hemineglect (if non-dominant) -Homonymous hemianopsia (blindness in the same field of vision of each eye) -Left MCA: Right hemiparesis Right homonymous hemianopsia Aphasia -Right MCA: Left hemiparesis Left homonymous hemianopsia Left hemineglect if non-dominant

What symptoms warrant further work-up for cannot-miss diagnoses?

-Midline back tenderness -Trauma concerning for fracture -Weight loss, fever, or night sweats concerning for cancer or infection -Bowel or bladder changes, weakness, or neurologic deficit concerning for cord compression.

How come you don't use digital blocks in high-pressure injection injuries?

-Might increase intracompartmental and tissue pressure and worsen ischemia.

What is difference between common migraine and classic migraine headaches?

-Migraine without aura = common migraine -Migraine with aura = classic migraine: Aura = Scotomata, focal neurological deficits, zig-zag lines in vision

What is the most common cause of the nephrotic syndrome in children?

-Minimal change disease

What are advantages to using fentanyl?

-Minimal effect on blood pressure -Optimal for analgesia and procedural sedation in patients with hypotension.

What are the minor and major forms of erythema multiforme?

-Minor presentation- self-limited rash of extremities and no mucous membrane involvement. -Outpatient supportive care -Major form - more severe. -Starts with prodromal viral illness then progresses to a rash that involves palms or soles and mucous membranes. -Major EM - Admitted & observed to monitor for further disease progression and treat accordingly.

What are triggers for hepatic encephalopathy?

-Mnemonic "LIVER" -Librium - sedatives -Infection -Volume depletion - dehydration -Electrolyte abnormality -RBC in gut - GI bleed

Why is this baby still crying?

-Mnemonic IT CRIES I—Infections: meningitis, UTI, sepsis T—Trauma: intracranial bleed, fracture, nonaccidental trauma C—Cardiac: arrhythmia R—Reaction to meds, Reflux, Rectal or anal fissure I—Intussusception E—Eyes: corneal abrasion, foreign body, glaucoma S—Strangulation, Surgical process: torsion, hernia, tourniquet

What are indications for HBO therapy in CO poisoning?

-Mnemonic NEPAL 25: -Neurologic changes -EKG changes -Pregnancy COHb level >15% -COHb level >25% -Altered mental status -Cardiovascular compromise -Myocardial ischemia -Syncope -Dysrhythmia -COHb level >25% -Pregnant patient with COHb level >15%

What is the classic triad for normal-pressure hydrocephalus?

-Mnemonic: Wet, wobbly, and weird. -Altered mental status -Ataxia -Incontinence.

How do you treat cocaine toxicity?

-Monitor vital signs -Give sedation to decrease sympathetic outflow which resolves the tachycardia and hypertension and further hyperthermia because of muscle relaxation.

What is a fracture of the proximal third ulna and a dislocation of the radial head called?

-Monteggia fracture "GRUM" -Complication: Radial nerve injury

What age group is SCIWORA more common in?

-More common in younger children than in older children and adults, although elderly persons can be affected.

What are advantages and disadvantages of succinylcholine compared with rocuronium?

-More rapid onset and shorter duration of action than nondepolarizing neuromuscular blocking agents. -4 Risks: -Bradycardia -Hyperkalemia -Masseter spasm -Malignant hyperthermia.

What is advantage of trop over other markers?

-More specific for AMI than CK-MB -High values predict complications and mortality

What is advantage of atypical antipsychotic agents (second-generation antipsychotics) over typical antipsychotic agents (first generation)?

-More specifically target dopamine receptors or inhibit serotonin reuptake -Lower risk of extrapyramidal side effects and tardive dyskinesia -more effective in managing the negative symptoms of psychoses: -such as affective flattening or blunting (a reduction of the external signs of emotion), -Alogia (decreased speech) -Poverty of speech. Eg Atypical anti-psychotics: -Abilify (aripripazole) -Clozapine -Olanzapine

Intussusception

-Most comm cause of sbo 6 mths to 3 y/o -Intermittent abd pain, pulling legs to chest. -Red currant jelly stool -Lethargy -Palpable and mass, right hypochondrium sausage mass -US image modality of choice, "Doughnut" sign -Contrast enema test of choice for diagnostic and therapeutic reduction

Ventricular Septal Defect in infant

-Most comm congenital cardiac lesion -Signs of CHF: trouble breathing -Hepatomegaly from CHF -Poor Weight gain or weight loss because tiring while feeding. -No cyanosis

When does erosion into the tracheoinnominate artery occur after tracheotomy?

-Most common 1 to 3 weeks after the procedure. -Immediate treatment should include direct pressure and hyperinflation of the tracheostomy tube cuff with gentle tube traction, which provides direct internal pressure to the bleeding artery. -Urgent consultation from ENT -If bleeding is not controlled with the actions described, then an endotracheal tube should be placed below the bleeding innominate artery with the assistance of a flexible nasopharyngoscope or bronchoscopy and advanced past the tracheostomy tube while withdrawing the tracheostomy tube. An endotracheal tube placed in this manner can be used to ventilate the patient, reduce aspiration of blood, and allow the physician to apply internal digital pressure to the artery while the patient is transferred to the operating room for arterial repair by an ENT or thoracic surgeon.

What are the most common cause of small bowel obstruction in the United States?

-Most common cause are adhesions (post-operative) #2 Neoplasms #3 Hernias.

What is most common cause of death in acute liver failure, and how do you treat it?

-Most common cause of death in ALF: Intracranial hypertension, cerebral edema -Risk is related to ammonia level -TX of IC Htn: HTS(hypertonic saline), mannitol, indomethacin

What is Steakhouse syndrome?

-Most common cause of distal obstruction (improperly chewed meat)

What is the most common cause of polymorphic ventricular tachycardia (VT) vs monomorphic VT?

-Most common cause of polymorphic ventricular tachycardia (VT) - myocardial ischemia -Most common cause of monomorphic VT - re-entrant mechanism through scarred myocardium

What are the most common causes of acute chest syndrome in sicklers? What is treatment for acute chest syndrome?

-Most common causes: -Pulmonary infections (usually chlamydia / mycoplasma) -Pulmonary infarctions -Fat embolism -Empiric TX: -O2 (hypoxemia out of proportion to CXR findings is the rule)(also is noted in pneumocystis jiroveci pneumonia [PJP]) -Antibiotics (ALWAYS include a macrolide) -Mechanical ventilation (13% in one large study) -Incentive spirometry -Pain management -Albuterol Bronchodilator therapy (even if not wheezing) -Transfusions (especially if at high risk)

When does infective endocarditis occur with Prosthetic valves?

-Most common during first two months post-op -Most frequently encountered pathogens in early PVE (within two months of implantation) were S. aureus and coagulase-negative staphylococci (Coagulase-neg = skin flora like S. Epidermidis)

What is most common international causes of acute liver failure? What is most common causes of acute liver failure in US?

-Most common international causes of acute liver failure: HAV, HEV -Most common US cause of acute liver failure: Acetaminophen-induced hepatotoxicity Tx: Acetylcysteine

What are 5 facts to know about renal transplants?

-Most common solid organ transplant -Transplant location: retroperitoneal in pelvis -Hepatitis C is very common -Patients receive azathioprine, cyclosporine and prednisone -Cyclosporine is nephrotoxic

What joint does osteoarthritis most commonly affect?

-Most commonly affects the knees.

What mechanism are burst fractures most commonly associated with, and are they considered stable or unstable fractures?

-Most commonly associated with falls and motor vehicle collisions. -All burst fractures should be considered unstable

At which levels does unilateral facet dislocation most likely to occur?

-Most commonly occur at the level of C3-C7 due to the relatively flat articular processes in this region. -Typically stable and might not present with any neurologic compromise. -Occur secondary to flexion-rotation forces

Does testicular torsion most commonly result from internal or external rotation?

-Most commonly results from internal rotation, so if you're attempting detorsion, start with external rotation.

What ECG changes occurs most commonly occur with pulmonary embolism, and what is the classic ECG finding?

-Most commonly tachycardia -Classically S1Q3T3,

What is profile of patient with sigmoid volvulus, and what is initial management?

-Most often affects adults 60 to 70 years old. -Constipation -Institutionalized neuropsychiatric patient "Sigmund Freud loves sipping coffee while laying on bent inner tube in river." Sigmund = sigmoid and old man. -GRADUAL onset pain Triad: 1) Abdominal pain 2) Distention 3) Constipation -Initial management: -Sigmoidoscopy for endoscopic detorsion. -Endoscopic decompression is successful up to 90% of cases. -If gangrenous bowel present or endoscopy is not successful, do surgery. -Mortality rate for sigmoid volvulus 20%. -If gangrenous bowel >50% mortality.

Most patients with food impaction have ____________ ____________ _______________.

-Most patients with food impaction have underlying esophageal pathology

What does physical exam of patients with GBS reveal?

-Motor weakness and either hyporeflexia or areflexia.

How do neonates with undiagnosed CHD present to the emergency department, and if during first 2 weeks of life what diagnosis and treatment should be considered?

-Mottled cyanotic skin -Shock -Shock or cyanosis occurring in the first 2 weeks of life strongly consider undiagnosed CHD given that the ductus arteriosus is closing. -Treatment with prostaglandins can be lifesaving. -Also consider septic shock

HSV-1 affects which part of the body?

-Mouth -HSV-1: Stomatitis, fever, decreased fluid intake, oral lesions, corneal ulcers (steroids are contraindicated) Grouped vessicles = Herpes -HSV-1 can cause encephalitis -HSV-2 can cause aseptic meningitis

35 y/o female presents with c/o painful vision loss in one eye and various motor deficits appearing over a few weeks. On exam you find she cannot with lateral gaze to right and left she cannot look at her nose with either eye. What is the diagnosis? What test confirms the DX? What is TX?

-Multiple Sclerosis -Multiple neurological deficits separated by time interval -Demyelination of multifocal areas of CNS → slowed nerve conduction -30s, F > M (males have more progressive disease) -#1 presentation optic neuritis -Unilateral (painful vision loss in 1 eye.) -Central vision loss, pain with eye movement and papillitis (papilledema of one eye) -Pathognomonic: Bilateral internuclear ophthalmoplegia (eyes can't look at nose) -Diagnosis: MRI (plaques), LP (increased protein, increased IgG, oligoclonal bands) -Visual evoked response is abnormal - evaluates the conduction of electrical impulses from the optic nerve to the occipital cortex of the brain -TX: for exacerbation short course of steroids, ACTH, plasma exchange

How can you tell neonate has gastroesophageal reflux disease?

-Multiple bouts of spit up or wet burps soon after feeds.

Why are murmurs not a reliable sign of congenital heart disease in a neonate?

-Murmurs are present in more than 50% of newborns who have normal hearts.

What must ED physician do with patient with flashes of light in peripheral visual field, floaters and visual field cuts like "Lowering of a curtain"? Can retinal detachments be ruled out by a normal direct ophthalmoscopic examination? Is there typically pain in the eye or headache associated with a retinal detachment?

-Must be evaluated by an ophthalmologist within 24 hours for concerns of a retinal detachment. -No! -It is a diagnosis based on history. -Cannot be ruled out solely based on a normal direct ophthalmoscopic examination. -No pain. Risk factors: DM, sickle cell, previous hx of RD, family hx, near-sighted, advanced age

Are these infections associated with salt or fresh water? -Mycobacterium marinum (acid-fast bacillus) -Areomonas hydrophila

-Mycobacterium marinum (acid-fast bacillus) -Home salt water tanks -Chronic cutaneous granulomas form Areomonas hydrophila: fresh water -Cellulitis and gastroenteritis

What are the 3 complications of AMI seen in first 2 weeks post-MI, and how are they all treated?

-Myocardial rupture of LV free wall: get acute tamponade, hypotension and death -Papillary muscle rupture (first week post-MI): get acute MR and acute onset CHF -Septal wall rupture (7-10 days post-MI): get acute VSD with acute onset CHF or Ant. or inf. MI -All need hemodynamic support, IABP, OR

If you're treating a child or a young adult who has signs of heart failure and a viral prodrome, what diagnosis do you consider?

-Myocarditis.

Tachycardia out of proportion to fever should raise the suspicion for ____________?

-Myocarditis.

How does rhabdomyolysis cause ATN? What causes rhabdomyolysis? How do you diagnose it? How do you tx it?

-Myoglobin clogs tubules -Myoglobin causes positive dip for heme, but no RBCs seen on micro -Causes -Trauma, Crush -Burns, Electrical injury, TASER -Heat stroke, "Found down" -EtOH, other drugs -Electrolyte abnl - hypokalemia -DX: -CK > 5 times normal = diagnosis -(more sensitive marker than myoglobin itself) -Dramatic acute increase in creatinine (Cr)example: increases 1 to 10 in same day. TX: -IVF -Alkalinization of urine with bicarbonate- prevents precipitation of myoglobin -Treat hyperkalemia and hypocalcemia

What are the sign's and sx's or dx of items below? -Myopathy: ? -Peripheral neuropathy: ? -Unexplained syncope: ? -Phenytoin (Dilantin) is contraindicated in: ? -Pontine hemorrhage: ?

-Myopathy: PROXIMAL WEAKNESS > distal, NORMAL reflexes and sensation normal -Peripheral neuropathy: DISTAL WEAKNESS > proximal, DECREASED reflexes -Unexplained syncope: Consider vertebral artery ischemia -Phenytoin (Dilantin) is contraindicated in 2° and 3° AVB -Pontine hemorrhage: Pinpoint pupils (interruption of sympathetic outflow + unopposed parasympathetic activity)

On exam an elderly female presents with: -"Hung up" reflexes (prolonged relaxation phase of DTRs) -Hypothermia -Non-pitting periorbital edema (puffy eyelids) -Generalized non-pitting edema What is diagnosis?

-Myxedema Coma

Patient presents with severe hypothyroidism leading to decreased mental status, hypothermia, and other symptoms related to slowing of function in multiple organs. What is the diagnosis?

-Myxedema coma -Occurs in elderly females in winter -Medical emergency with a high mortality rate

What is encapsulated Gram negative diplococcus?

-N. meningitidis

What is presentation of acute arsenic toxicity?

-N/V/D -Abdominal pain. -Garlic odor of the breath and stool. -Dehydration, hypotension. -QTc prolongation with subsequent torsades de pointes -Shock -Respiratory distress -Acute encephalopathy

What is the best test for C. trachomatis and N. gonorrhoea in men?

-NAAT, Nucleic Acid Amplification Technique with a urine sample.

Are Factor VIII and von Willebrand factor synthesized in the liver?

-NO! -Although many of the proteins and coagulation factors are synthesized in the liver, Factor VIII and von Willebrand factor are not. -Synthesized in endothelial cells.

Do you replace a G-tube that has been dislodged within 2-3 weeks of placement? What is treatment in this case?

-NO! -Don't try to replace a G-tube in the first 2 to 3 weeks after it was placed - get a consult instead. -G-tube tracts mature after 2 to 3 weeks, so dislodgement of the G-tube has risk for: -Intestinal content leakage -Peritonitis. -Treatment: 1) Imaging 2) Antibiotics 3) Surgical consultation

Should you refreeze a frostbitten injury? What is treatment for frostbite and blisters from it? What is the rule for amputation in frostbite?

-NO! Refreezing is VERY BAD Causes more damage than waiting for evacuation and definitive treatment ED treatment -Rapid rewarming: Circulating water (40o C) Blister management Clear blisters should be debrided Hemorrhagic blisters should be left alone -"Frostbite in January - amputate in July" Conservative surgical debridement after demarcation

Are cobras are not native to the United States?

-NO! Thank goodness!

Do you re-dose lytics if re-infarct?

-NO!!! -Do not re-dose lytics if re-infarct. Go straight to Cath lab.

Are continuous albuterol and steroids beneficial with bronchiolitis?

-NO. They are most beneficial in children with acute asthma exacerbations, not bronchiolitis. -In child < 2 y/o with no asthma risk factors who has concurrent URI symptoms and no improvement after a trial of albuterol has bronchiolitis

What is difference in treatment of symptomatic or asymptomatic UTI in pregnant patients?

-NONE TX ALL PREGNANT PATIENTS WITH UTI WITH SX OR ASX. -Increased incidence of UTI during pregnancy -Increased risk of bacteremia, septic shock -Asymptomatic pyuria or bacteriuria should be treated aggressively in pregnant women -UTI can precipitate preterm labor -Obtain urine culture -Consider inpatient treatment for pyelonephritis -Treatment: Cephalosporin, amoxicillin, nitrofurantoin x 7-10 days

What are 4 causes of reversible dementia?

-NPH -Subdural hematoma -Depression -Drug and alcohol dependence

A HIV patient presents with severe lactic acidosis. Why does it occur, and how do you treat it?

-NRTIs -(Nucleoside reverse transcriptase inhibitors-) can cause mitochondrial damage inhibiting cellular energy production resulting in lactic acidosis -represents a serious metabolic manifestation of mitochondrial toxicity that can lead to death -May start suddenly or gradually Sis-Nonspecific: include abdominal pain, weight loss, malaise, fatigue, rapid breathing, tachycardia -STOP DRUG NRTI, bicarbonate, glucose, riboflavin -Mortality can be as high as 60%

What is treatment of choice for reactive arthritis?

-NSAID, commonly indomethacin, and if a chlamydial infection preceded the arthritis, adding an antibiotic might reduce recovery time.

Formulas for: -Pseudohyponatremia -Water deficit for hypernatremia -Parkland formula for burns: -Anion Gap -Serum osmolality

-Na+ drops 1.6 mEq/L for every 100 mg/dL increase in glucose over 100 -TBW = Wt (kg) x 0.6 -Water deficit in liters = TBW x ( [current Na/ 140] -1) -4 mL/kg/%TBSA -Adult: for > 15% TBSA partial or full thickness burns -Give 1/2 of total fluid over 1st 8 hours then remaining 1/2 over next 16 hours. -Children: 4 mL/kg/% TBSA of partial thickness or full thickness burns + 24-hr Maintenance fluid. -Give 1/2 of total fluid over 1st 8 hours then remaining 1/2 over next 16 hours. A-G = Na+ - (Cl- + HCO3-) ≤ 12 2Na +Glu/18 + BUN/2.8 + EtOH/4.6 Remember 1.8 + 2.8 = 4.6

Patient with h/o IVDA has severe pain of leg. Exam shows crepitant cellulitis. What is diagnosis?

-Necrotizing Soft Tissue Infections -Subcutaneous gas -Myonecrosis (clostridial, non-clostridial) -Necrotizing fasciitis (rapid dissection and necrosis in superficial and deep fascial planes)

Pain Out of Proportion (POOP) -Abnormal Vital sign (esp. tachycardia) -↑↑↑ WBC count -Odor -Rapid change -Subcutaneous air (crepitus) When patient has above findings what must you r/o?

-Necrotizing fasciitis

What antibiotic is needed for corneal abrasion secondary to contact lens use?

-Need pseudomonas coverage by ciprofloxacin, ofloxacin, or tobramycin. -Needs close f/u with ophthalmologist

What is treatment for hepatic encephalopathy?

-Neomycin -Lactulose -Low protein diet -Avoid sedatives -Avoid bicarbonate (alkalosis can worsen encephalopathy)

Presence of protein and blood in the urine is consistent with ______?

-Nephritis.

A HIV patient presents with acute flank pain with hematuria. What is diagnosis? Does non-contrast CT detect the pathology?

-Nephrolithiasis -Indinavir, a protease inhibitor, can crystallize in the kidney and form stones (4-22%) -Stones don't show up on plain x-rays or non-contrast CT

What is profile of Nephrotic Syndrome? What are the clinical features of it?

-Nephrotic Syndrome = Nephrosis -Nephrotic=chronic has low BP from low oncotic pressure from low protein -So have Chronic Renal Failure -Nephritic = acute Clinical Features -Massive proteinuria (>3g / 24h) -Hypoalbuminemia -Edema -Hyperlipidemia -Thrombosis -Get DVT/PE (b/c pee out anti-thromib 3)

What is difference between nephrotic and nephritic syndromes?

-Nephrotic pattern = proteinuria that is usually above 3.5 g/day and lipiduria, but few cells or casts = CHRONIC -Nephritic pattern = presence of red cells and +/- white blood cells, +/- red cell casts, and =/- proteinuria = ACUTE

What type of chemical weapon are VX and sarin? Which of these is the most potent one, and which is the most volatile? How do you treat it?

-Nerve Agents which cause cholinergic crisis. -VX is the most potent. -Sarin the most volatile. -Powerful inhibitors of acetylcholinesterase (SLUDGE, killer "B"s, paralysis, death) Tx: Oxygen, atropine, 2-PAM -Military Mark 1 auto injector kit -2 mg atropine and 600 mg 2-PAM

What are signs and symptoms of hyperthyroidism?

-Nervousness, tremor, insomnia -Heat intolerance, sweating -Tachycardia, palpitations -Hyperdefecation -Irregular menses -Goiter / thyroid bruit -Exopthalmos (Grave's only), lid lag graves only (the lids move more slowly than the eyes)

What is the most common causes of widened mediastinum in the posterior compartment?

-Neurogenic tumors

The presentation of the tetrad of: -Altered mental status -Autonomic instability -Hyperthermia -Muscular rigidity = ?

-Neuroleptic malignant syndrome (NMS) -Most commonly caused by drugs that antagonize dopamine receptors i.e. antipsychotic medications. -Also occurs predictably from the abrupt cessation of dopamine agonists used to treat Parkinson disease, like the combination of levodopa and carbidopa.

What are neuroleptics? What are the 4 side effects?

-Neuroleptics = First-generation antipsychotics (FGAs) - Haloperidol -Cause extrapyramidal side effects and tardive dyskinesia -Anticholinergic: -Delirium, fever, dry mouth, erythema, mydriasis -Alpha blockade: -Hypotension, syncope -QT prolongation -Increased risk of sudden death

Why is succinylcholine contraindicated in neuromuscular diseases like AML, MS?

-Neuromuscular diseases result in upregulation of acetylcholine receptors at the neuromuscular junction, which can cause an exaggerated hyperkalemic response to succinylcholine. -Succinylcholine is contraindicated in these patients regardless of time of diagnosis or severity of disease.

How common is pre-tibial Myxedema in Graves, and what is it?

-Rare manifestation of Graves' disease -Bilateral, elevated, firm dermal nodules and plaques -Accumulation of mucopolysaccharides

Should the ABCD2 score be used to determine if a patient can be safely discharged from the emergency department?

-No. -Can be used to help approximate a patient's risk for stroke following a TIA, although it is less accurate than hoped. -Should be viewed as only one factor in determining if a patient presenting with TIA requires further expedited workups.

Is ultrasound sensitive for detecting placental abruption?

-No. -Sensitivity of ultrasound findings for diagnosis of abruption is only 25 to 60 percent

Can you detect Bordetella Pertusis with blood culture?

-No. B. pertussis does not invade beyond the submucosal layer in the respiratory tract and is almost never recovered in the bloodstream.

Should one perform a sexual assault examination more than 96 hours after an assault?

-No. Evidence specifically for forensic purposes cannot be used if there is more than a 96-hour delay from assault to examination.

Do hallucinogens require gastric decontamination?

-No. Hallucinogens are rapidly absorbed and do not require gastric decontamination

Do initial radiographic findings in pulmonary contusion reliably estimate the severity of pulmonary contusion?

-No. Initial radiographic findings don't reveal the seriousness of the condition.

Is it necessary to perform the entire forensic evidence kit in every circumstance?

-No. The collection of evidence should be tailored to the specifics of the assault.

Adult 30 y/o male presents with watery penile discharge. What is dx and tx?

-Non-Gonococcal urethritis -Watery or no discharge -Few findings on smear Chlamydia, HSV, Trichomonas, Ureaplasma, -TX: azithromycin (1g x single dose) doxycycline (100 mg BID x 10 days)

What type of pulmonary edema in HAPE results from hypoxia-induced pulmonary artery hypertension?

-Noncardiogenic pulmonary edema

What is the single best tx for acute CHF?

-Noninvasive ventilation

What does nonpalpable purpura vs palpable purport indicate?

-Nonpalpable purpura = think low or dysfunctional platelets -Palpable purpura = think angiopathy / vasculitis

What is clinical picture of Yersinia enterocolitis?

-Nonspecific and includes gastroenteritis-type symptoms. -Has Bloody diarrhea -Uncooked pork can be a source. -Diagnosis requires a positive stool culture or real-time polymer chain reaction (PCR) testing. -Standard stool cultures are inadequate

What are the indications for the newer oral anticoagulant agents?

-Nonvalvular atrial fibrillation -Treatment and prevention of venous thromboembolism.

What is treatment for HHNS?

-Normal saline -Average fluid deficit 8-12 liters -Give ½ of deficit in first 12 hours, rest over next 24 hours -Initial 1-2 liter bolus as clinically indicated -Insulin infusion (usually lower doses than in DKA)

Diagnosis of pericarditis is supported by what type of ECG findings?

-Normal sinus rhythm -Diffuse ST-segment elevation -Diffuse PR segment depression. -Leads I and aVR can show reciprocal ST-segment depression

How reliable is Platelet function test to predict bleeding?

-Not reliable

What is profile of patient with SCFE?

-Obese male, more common in black males, -Child 8 to 16 years old -Acute onset

What are 4 risk factors for heat Illness?

-Obesity (insulation, poor skin blood flow) -Hyperthyroidism (increased heat production) -Drugs: PCP, amphetamines, cocaine (increase heat production) -Anticholinergics (can't sweat) -Alcohol (can't sweat, impaired behavior) -Burns (can't sweat) -Heart disease, beta blockers (can't increase cardiac output) -Diuretics (can't sweat)

Adult male patient presents with HA, n/v. On exam you find papilledema and CN 6 palsy. What is DX? What procedure is contraindicated?

-Obstructive Hydrocephalus - same signs/sx's as idiopathic intracranial HTN. Signs and symptoms of increased ICP (headache, nausea, vomiting, decreased LOC, papilledema, CN VI palsies) -Obstruction of CSF flow (tumor, postinfectious, post-SAH, VP shunt blockage) -Diagnosis: CT, MRI (dilated ventricles) DON'T DO LP!! (risk of herniation) -TX: Ventriculostomy, surgery (shunts)

At what age do breath-holding spells usually occur?

-Occur for the first time between 6 and 18 months and resolves by or before 6 or 7 years.

When does acute radiation proctitis occur?

-Occurs during or within six weeks of radiation therapy.

What is Pseudocoarctation syndrome?

-Occurs in MVA: caused by periaortic hematoma compression of the thoracic aorta causing upper extremity hypertension and decreased pedal pulses.

What is hypertrophic cardiomyopathy?

-Often familial autosomal dominant -Asymmetric thickening of septum causing 2 problems: -Noncompliant ventricle with decreased diastolic filling (Rotten diastolic function - Cannot relax and fill up) -Dynamic obstruction of LV outflow

What is Landry-Guillain-Barré Syndrome often preceded by? What is the hallmark finding of GBS? What is the most common finding of GBS?

-Often preceded by viral syndrome (gastroenteritis, mycoplasma) -Progressive ascending weakness is most common -Hallmark finding: Loss of DTRs

What is presentation of Giant cell arteritis, commonly called temporal arteritis? How can this affect the vision? How is diagnosis is made of Giant cell arteritis, and what is the treatment?

-Older patients -Headache gradually worsens over days -Worse at night -Fatigue -Anorexia -Fever -Myalgias -Tenderness to palpation over the temporal artery -Impaired vision in 50% (posterior ciliary artery) -May be presenting symptom -May present as amaurosis fugax -Bilateral blindness in 50% of untreated patients -Elevated ESR and temporal artery biopsy. -Treatment: -Ophthalmology consult -High-dose steroids IV then oral steroids.

What is most common cause of seizure in afebrile children <2 y/o? What are 2 DX's to consider if you have pediatric patient with sz and diarrhea?

-Pediatric sz: Hyponatremia (most common in afebrile children <2), -Shigella & Rotavirus -Gastroenteritis (rotavirus, Shigella), so child with sz & diarrhea = hyponatremia or shigella

In general Protected Health Information, or PHI may be released without written authorization when used for purposes of treatment, operations, or payment. What is the one exception?

-One exception is for psychotherapy notes, which typically cannot be disclosed without consent, except in cases of treatment, specific legal matters, and if there is a significant public safety concern.

What is Duke criteria for infective endocarditis and what is the mnemonic?

-One of 3 categories: -2 major criteria -1 major + 3 minor criteri -5 minor criteria -Mnemonic: Be Joan of Arc Major: -Blood cx's x2 or persistent -Echo evidence of vegetation and valvular regurgitation (Diagnosis: ultrasound (TEE) for vegetations- Whenever see TEE as an answer choice on Board exam ALWAYS pick this) Minor: -Janeway lesions - nontender, hemorrhagic plaques on the palms and soles -Osler's nodes - tender nodules on the tips of the fingers and toes (Osler = Ow!) -Aneurysm/Abuse (mycotic) IVDA -Nephritis -Other predisposing heart condition (artificial valve) -Fever -Arterial emboli - septic emboli -Roth spots(retinal hemorrhages with central clearing)/Rheumatoid factor -Culture not meeting major criteria

How common is Listeria monocytogenes meningitis, and what is profile of patient?

-Only about 2% of cases of meningitis -Very young patients (<1 month) or older patients (>50 years) or immunocompromised patients

What is emergency department for sialolithiasis?

-Only therapy needed in the emergency department is analgesia and sialagogues (like lemon drops) to help promote passage of the stone. -If the stone does not pass, patient follows up with an ENT specialist.

Should neonates should be intubated with an uncuffed or cuffed ETT?

-Only uncuffed ETT.

Many medications are associated with constipation, but most commonly?

-Opioids -Iron supplements -Anticholinergics. -Calcium channel blockers, antiepileptics, and most psychiatric medications also cause constipation.

How do you treat Valley fever, (coccidioidomycosis) in pregnant women, severe disease, immunosuppression, or cardiopulmonary disorders?

-Oral azole anti fungal agent i.e. ketoconazole, fluconazole, or itraconazole.

What is most common GI tract infection of AIDS patients?

-Oral candida

What are advantages of both direct thrombin inhibitors and Xa inhibitors? What are the indications for their usage?

-Oral dosing -Predictable effects -Fewer food and drug interactions -Shorter plasma half-life -Improved efficacy-safety ratio -Once or twice a day dosing -Indications: -VTE -A Fib-Nonvalvular to prevent stroke -ACS

What is the safest treatment for hypokalemia?

-Oral replacement safest -Correct acid-base abnormality -IV replacement: No more than 40 mEq/L and no faster than 40 mEq/hour -Hypokalemia often is associated with hypomagnesemia - KNOW that Resistant hypokalemia requires replace Mg++ & K+

In what type of arthritis are Bouchard and Heberden nodes found?

-Osteoarthritis -Bouchard nodes of PIP joints -Heberden nodes of DIP joints

Do you prescribe otic or oral antibiotics if you're concerned about an underlying infection for perforated tympanic membrane.

-Otic antibiotics. -Systemic antibiotics are less effective in the treatment of a ruptured tympanic membrane

What is the most common cyst associated with ovarian torsion? Is the cyst benign or malignant usually? Why?

-Ovarian or Adnexal Torsion -Most associated with benign tumors or cysts -Dermoid cyst most common -Malignant tumors usually fixed, torsion rare -Severe abdominal pain, constant, unilateral Nausea, vomiting, usually afebrile Vaginal bleeding is uncommon -Exam: Unilateral tenderness, rebound or mass -Diagnosis: Ultrasound (look for flow but may appear normal if untorsed), laparoscopy -Rule out ectopic, appendicitis, PID

What are causes of hypercalcemia mnemonic?

-PAM P SCHMIDT -Parathyroid: hyperparathyroidism (most common) -Addison's disease -Multiple myeloma -Paget's disease (during immobilization) -Sarcoidosis -Cancer -Hyperthyroidism -Milk-alkali syndrome -Immobilization -D vitamin -Thiazide diuretic

Thrombolytic for AMI may be considered when PCI is delayed by _________.

-PCI delayed > 90-120 minutes -Time from onset of infarction < 2 hours, PCI should be performed < 60 minutes -Time from onset of infarction is 2-3 hours, PCI should be performed within 60-120 minutes -Time from onset of infarction is between 3-12 hours, PCI should be performed < 120 minutes

Which of the 3 forms of plague is very contagious, and how does it present?

-PNEUMONIC PLAGUE: VERY contagious -Incubation 2-3 days, inhalation of aerosolized bacteria (REQUIRES RESP. ISOLATION) -Fever, cough, BLOODY sputum, shock, DIC, ↑LFTs; Gram's stain, culture, serology; -CXR: Extensive LOBAR consolidation TX: streptomycin, doxycycline, chloramphenicol, vaccine -Bubonic plague: Not contagious -Septicemic plague: Complication of above

What are positive and negative predictors of UGIB? What are predictors for UGIB requiring urgent intervention?

-POSITIVE predictors of UGIB -Melena (by Hx or exam) -NG lavage showing blood or coffee grounds -Serum BUN:creatinine ratio > 30 -NEGATIVE predictors of UGIB -Blood clots in the stool -PREDICTORS of severe UGIB requiring urgent intervention -Red blood on NG lavage -Tachycardia -Hb < 8 g/dL Blatchford score predicts which pts do NOT need urgent intervention don't need to know more detail of scoring system

What is pathology of post renal failure? What are the causes? What is most common cause?

-POST RENAL failure = obstruction -Causes: -Bilateral kidney -Crystals in tubules -Stones in calyces -Bilateral ureteric -PAPILLARY NECROSIS from too much NSAID or elderly multiple stones, surgically cut retroperitoneal blood, pus or scar, Urethral prostatic hypertrophy (most common) neurogenic bladder phimosis, meatal stenosis

What is most common cause of Upper GI Bleeding in adults? What is common cause of UGIB in pregnancy?

-PUD most common (usually duodenal) -Gastric erosions (alcohol, NSAIDs) -Varices -Mallory-Weiss tears -Esophagitis (common in pregnancy)

Tenderness + soft tissue swelling at the physis + negative radiograph = _______________________?

-Pediatric type I Salter-Harris fracture.

What are the 3 types of pediculosis?

-Pediculosis = lice -Head lice -Body lice -Pubic lice = Crabs Tx: pyrethrin, permethrin, malathion

What is difference between pemphigus vulgaris and bullous pemphigus?

-PV has +Nikolsky sign. -Bullous pemphigus has -Nikolsky sign. Pemphigus vulgaris: -Vulgar -People may talk in a vulgar language. (Talk - mouth - blisters on the oral mucosa) -Usually, Younger people are vulgar. (Younger patients are affected 40-60 y/o) (BP is disease of elderly) -Vulgar people have painful personalities and PAINFUL bullous lesions. -Vulgar people are shallow and superficial (Superficial blisters that are above the basal layer) -Since they are superficial, they will rupture easily. (Nikolsky's sign positive) -And die.

When are steroids indicated for the management of severe PCP?

-PaO2 >70 mm Hg -A-a gradient of 35 or more -O2 saturation <92% on room air.

What are the 6 P Sign of acute ischemia (6 P's)

-Pain -Pallor -Paresthesias -Paralysis -Pulselessness (late finding) -Poikilothermia (polar, cold)

What is clinical presentation of anterior uveitis?

-Pain -Photophobia -Blurred vision -Ciliary flush -Constricted or irregularly shaped pupil.

What is the most common symptom for diverticular disease?

-Pain -Steady, deep, LLQ location (Western world)

What are the classic findings for perforated tympanic membrane?

-Pain before perforation, then suddenly it feels better.

What is one of the key clinical signs of necrotizing soft issue infection?

-Pain out of proportion to examination findings.

What's the classic presentation for acute mesenteric ischemia?

-Pain out of proportion to physical examination findings.

What characteristics are demonstrated by nearly all patients with excited delirium syndrome?

-Pain tolerance -Tactile hyperthermia not hypothermia

What is Erythema Nodosum (EN), and how do you treat it?

-Painful, non-ulcerative, violaceous nodules (localized vasculitis) on anterior tibia, arms, trunk, -Painful red nodules -A marker for systemic disease -Drug reaction (oral contraceptives, sulfa, PCN) -Systemic infection (TB, fungal) -Sarcoid -Inflammatory bowel disease (ulcerative colitis) -Malignancy (leukemia, lymphoma) -Women 30-50 -Resolves in few weeks -TX underlying disease

Meckel Diverticulum

-Painless rectal bleeding with our without abdominal pain -Rule of 2's: -2% of population has it -Child <2y/o -2 inches long -Within 2 feet of ileocecal valve -2x's more in males vs females -Meckel technetium scan to evaluate for ectopic gastric tissue -Meckel's diverticulitis when ectopic gastric tissue becomes inflamed and has peritonitis.

Is priapism painless or painful?

-Painless when related to trauma or other high-flow state. -Painful when to medications or sickle cell disease.

What are the two classic types of breath-holding spells?

-Pallid and cyanotic (most common). -Breath holding spells are a benign issue and generally do not require further workup in the emergency department. -Reassurance of caregivers is the key. -Explain the pathophysiology of what occurred: crying leading to stimulation of the vagal nerve, which then leads to a syncope-type reaction.

How do you distinguishing between excess endogenous insulin from excess exogenous insulin?

-Pancreas cleaves proinsulin to insulin + immunoreactive C-peptide -Excess endogenous insulin = high levels C-peptide -Excess exogenous insulin = No c-peptide.

What is a pantaloon hernia?

-Pantaloon: indirect and direct at the same time ipsilateral, concurrent direct and indirect inguinal hernias. Hernial sacs are present on both sides of the inferior epigastric vessels

What are potential problems with external rewarming in hypothermic patient?

-Paradoxical core afterdrop and acidosis -Focus on the trunk first

What are sided effects of midazolam?

-Paradoxical excitement -Resp depression

What neurologic complication may occur with mastoiditis?

-Paralysis of the seventh nerve, causing findings similar to Bell palsy.

What is the most frequently fractured bone of the skull in infants and children?

-Parietal.

Partial sz: What are the following types of partial sz's? -"Jacksonian march-" ? -Simple - /? -Complex - ?

-Partial -Focal seizures imply structural lesions -"Jacksonian march:" Focal seizures that may progress to generalized seizures -Simple: No LOC, mental status is preserved -Complex: Temporal lobe, altered mental status, -Bizarre behavior affected; "psychomotor" seizures

What is a frequently recognized pathogen in myocarditis?

-Parvovirus B-19

How soon must you give Hepatitis B Immune Globulin (HBIG) after the exposure?

-Passive immunization (pooled antibodies) -Effective within 1 week of exposure

What part of kidney is affected by Glomerulonephritis (Acute Nephritic Syndrome), and what are the 2 causes? What is the treatment?

-Pathology: -Immune complexes/antibodies clog up glomeruli - so can't pee, get edematous, HTN, oliguria -UA: Hematuria, pyuria, RBC casts, mild/moderate proteinuria -Causes -Autoimmune / Vasculitities: -KNOW Post-streptococcal GN -KNOW IGA nephropathy -SLE, HUS, TTP, HELLP, HSP Tx: -Steroids, immunosuppressive agents

What is pathology of Acute Interstitial Nephritis (AIN), and what are the causes? What is the clinical triad on presentation? What is seen on UA? What is the treatment?

-Pathology: -Most often induced by drug therapy -Also Immune mediated -Causes: Drugs: -Penicillin, Sulfa -NSAIDs -Diuretics -Infections -TRIAD: -Fever -Rash -Eosinophilia UA: -Pyuria -WBC casts -Eosinophiluria -TX: -Treat underlying infection -Remove offending agent(s)

What is the indication for performing thoracotomy in the emergency department?

-Patient presenting with penetrating chest trauma who has a traumatic arrest in the emergency department or shortly before arriving.

Who is at high risk for osmotic demyelination syndrome with rapid serum sodium correction?

-Patients with severe hyponatremia but without severe neurological symptoms. -They have had a gradual development of hyponatremia.

What are the indications for performing cystourethrography in pelvic trauma?

-Penetrating mechanism -Inability to void -Blood at the meatus -Scrotal hematoma -Perineal bruising -Unstable pelvic fracture -High-riding prostate -Perform urethrography before cystography to confirm an intact urethra and assess for possible bladder injuries.

All children with acute rheumatic fever should receive __________ regardless of culture results.

-Penicillin (erythromycin for penicillin-allergic patients) for strep

What is the appropriate treatment of primary and second syphilis? You give the treatment, and 6 hours later patient develops fever, chills, headache, myalgia, rash. What is the diagnosis?

-Penicillin G benzathine 2.4 million units IM. -Jarisch-Herxheimer reaction - serum sickness -Antibiotic treatment causes organism death and the release of endotoxins -Comes on 2-6 hours after the onset of treatment Lasts a few hours -Occurs in 50% of cases of primary syphilis (90% of secondary cases) -TX with acetaminophen two hours before and after antibiotic treatment

What is first-line treatment for periodontal infection?

-Penicillin or clindamycin. -Patient might eventually require a tooth extraction, but it rarely needs to be performed in the emergency department.. Dentists prefer that the patient start a course of antibiotics before extraction.

Patient presents with -Hypotension -JVD -Muffled heart sounds -Pulsus paradoxus What is diagnosis?

-Pericardial tamponade

What is a tet spell (Hypercyanotic spells) ?

-Period of profound cyanosis occurring because of almost total RVOT obstruction. -Occurs when infant becomes agitated or in older, uncorrected children after vigorous exercise. -Worsening of the RVOT obstruction & decreased pulmonary blood flow

How does ITP present?

-Petechiae or bruising without other significant clinical findings. -Symptoms can include bleeding from the nose, mouth, blood in the urine, and heavy bleeding in a menstruating female. -Intracranial hemorrhage can be life-threatening with this disorder, but it is rare with a platelet count above 20,000 without significant trauma.

What are symptoms of infectious mononucleosis?

-Pharyngitis with exudates -Posterior cervical lymphadenopathy -Splenomegaly (50%). -Fatigue -Sore throat -Lymphadenopathy.

When does physiologic jaundice occur and what is course of it?

-Physiologic jaundice peaks between days 3-5 -Resolves on its own by the second week of life.

What medication is contraindicated in organophosphorus poisoning?

-Physostigmine, -It is an acetylcholinesterase inhibitor like organophosphorus compounds However, this is useful for anticholinergic toxicity causing delirium.

What is Tinea versicolor, and what is profile of patient?

-Pityriasis (Tinea) Versicolor - NOT really a Tinea -Tinea versicolor is NOT a dermatophyte infection. The causative organisms are yeasts in the genus Malassezia -From poor hygiene. -Common fungal rash caused by Malassezia furor -Common in teenagers.

Rash appears in children & young adults -Etiology unknown -No epidemics, not contagious -Evolves over weeks Starts with a single salmon-colored lesion with raised boarder on trunk, 1-5 cm & then over 1-2 weeks spreads following the ribs. What is this rash?

-Pityriasis Rosea -Starts with Herald patch: Single salmon-colored lesion with raised boarder on trunk, 1-5 cm, "Heralds the arrival of the rash." -1-2 weeks after herald patch: Widespread eruption, pink maculopapular oval patches that follow the ribs ("CHRISTMAS TREE" pattern) -R/o secondary syphilis (if clinically indicated), drug reaction -Tx: Symptomatic, antihistamines -Resolution spontaneously in a few weeks.

Female who is 22 weeks pregnant presents with painless bright red bleeding. What is dx? What procedure is contraindicated? How accurate is US for diagnosing problem?

-Placenta Previa > 20weeks gestation: Implantation of placenta over the cervical os Increased incidence: Older, multiparity, smoking, prior c-section Diagnosis: Ultrasound highly accurate Pelvic exam contraindicated

In severe pancreatitis, __________________ might be required to deal with the hypertriglyceridemia.

-Plasmapheresis

What lung disease results from inhaling toxic substances, including coal dust (coal miner's lung, coal workers' pneumoconiosis, black lung disease) and silica?

-Pneumoconiosis- -It is a restrictive lung disease -Results in pulmonary fibrosis, which limits total lung volume and decreases oxygen perfusion across the alveoli. -Have gradual onset dyspnea -Imaging: Interstitial lung findings (a fine reticular pattern) can appear similar to interstitial pulmonary edema Tx: Steroids

What is one of the most common opportunistic infections in patients with HIV/AIDS>

-Pneumocystis pneumonia -Name of changed from Pneumocystis carinii to Pneumocystis jirovecii

In PEA with h/o cystic fibrosis what should be a strong suspicion for the cause of the patient's cardiac arrest?

-Pneumothorax is a common complication of CF -#2 most common cause of chest pain in CF patients -Occurs much more commonly than in the general public -3.5% of CF patients have spontaneous pneumothorax -20% recurrence rate if ptx.

What are the most common indicators of congenital heart disease in a newborn?

-Poor feeding with or without sweating -Irritability -Unexplained hypertension -Hepatomegaly -Pathologic murmur

Patient presents with petechiae, hypotension, T> 40 °C, decreased platelets, no meningismus or leukocytosis in setting of meningococcemia. What is prognosis?

-Poor.

What hormone is secreted by a germ cell tumor?

-Positive hCG test -HCG is secreted by the cancer cells in some of the germ cell tumors found in testicular cancer.

What are the indications for emergent thoracentesis?

-Possible pleural space infection -Relief of dyspnea -Evaluation of a new effusion of unclear etiology.

What is treatment for refractory VF or electrical storm & what treatment is contraindicated?

-Possible treatments after first-line therapy for VF fails: -Lidocaine -Isoproterenol -Propranolol -Esmolol. -Dopamine has a proarrhythmic effect, so CONTRAINDICATED for electrical storm or refractory ventricular arrhythmia.

What are definitions of the following d/o's? -Post-traumatic stress disorder: ? -Panic attack: ? -Obsessive - compulsive disorder: ? -Phobias: ?

-Post-traumatic stress disorder: Continued anxiety following a traumatic event, substance abuse -Panic attack: Recurring episodes of fear (impending doom) without identified stimulus -Obsessive - compulsive disorder: Repetitive acts or ritualistic behavior to relieve anxiety -Phobias: Unfounded fears that arouse a state of panic

What part of the female genital area is most commonly injured after sexual assault?

-Posterior fourchette

What are laboratory abnormalities that can indicate postpartum pituitary gland necrosis?

-Postpartum pituitary gland necrosis AKA Sheehan syndrome -Laboratory abnormalities: -Hyponatremia -Hypoglycemia -Anemia -Above all secondary to adrenal insufficiency.

What is the most common cause of acute glomerulonephritis in children 5 to 12 years old?

-Poststreptococcal glomerulonephritis -Infection is from a streptococcal infection (almost always group A streptococci) from either pharyngitis or a skin infection.

In addition to atropine, what other antidote do you give for OP poisoning?

-Pralidoxime (2-PAM) -Cholinesterase reactivating agent that treats both muscarinic and nicotinic symptoms

What is infective endocarditis most commonly associated with?

-Predisposing cardiac abnormalities -IVDA -Indwelling catheters -HIV -Poor dental hygiene

What factors cause you to get CT before LP in suspected meningitis?

-Predisposing factors for an abnormal CT: -Age at least 60 -Immunocompromised (HIV, immunosuppressive treatment and transplant pts.) -A history of CNS disease (mass lesion, stroke or focal infection) -Seizure within the last week -Abnormal neuro exam / altered mental status

What is eclampsia and what is timing of presentation with respect to pregnancy?

-Preeclampsia + new onset seizure -May occur antepartum, intrapartum, and up to 4-6 weeks post part postpartum.

What size ETT is recommended for premature neonate and full term neonate?

-Premature newborn - 2.5 uncuffed ETT (smallest size available) -Baby weighing 1.6 kg to 3 kg or more - 3.0 uncuffed ETT.

What are the contraindications for using flumazenil to reverse benzodiazepine poisoning?

-Presence of a proconvulsant coingestant and a history of convulsions. -Bupropion, both therapeutically and in overdose, can cause convulsions

What is Truncus arteriosus?

-Presence of a single trunk arising from the heart that functions as both the aorta and the pulmonary artery.

What is the acidosis in alcoholic ketoacidosis predominantly result from?

-Presence of beta-hydroxybutyrate (a ketoacid that is not typically detected as a ketone on urinalysis).

What differentiates iritis/Anterior uveitis from intermediate/posterior uveitis?

-Presence of leukocytes in the anterior chamber of the eye = Anterior uveitis(iritis) -Posterior Uveitis= no redness, no pain, +visual changes

Is the presence or absence of hematuria (gross or microscopic) predictive of renal injury in the setting of penetrating trauma?

-Presence or absence of hematuria (gross or microscopic) is NOT predictive of renal injury in the setting of penetrating trauma.

How do you dx PID?

-Presentation ranges from mild symptoms (dyspareunia, pelvic pain) to sepsis -Goal is to treat mild disease, assure correct diagnosis if seriously ill -Diagnostic criteria -Cervical motion tenderness OR uterine tenderness OR adnexal tenderness DX IS CLINICAL. (not dependent on specific tests) -Still send tests for gonorrhea, chlamydia; consider testing for HIV, syphilis TX: Regimens change; need to consult guidelines JUST KNOW need mulitple ABX

What are 2 high likelihood features of ACS from a patient's history?

-Previous MI -Known coronary artery disease.

What is primary factor determining survival from drowning? i

-Primary factor = duration of immersion -If submerged < 60 minutes and no obvious physical signs of death - START CPR

"You're not dead until you're warm and dead" applies to the resuscitation of patients suffering from ________________.

-Primary hypothermia- hypothermia directly from a cold environment -If patient is warmed to > 32°C (89.6°F) and has persistent asystole, then resuscitative efforts are futile and can be stopped.

What are the 2 types of Raynaud disease?

-Primary or secondary. -Primary - exaggerated response to the cold without another causal ailment. -Secondary - result of another condition and is the most common cutaneous complication of systemic sclerosis.

What are potential treatments for stable sustained monomorphic VT?

-Procainamide -Amiodarone -Sotalol -Lidocaine -Overdrive pacing -Synchronized cardioversion

What is the most commonly used emergency contraceptive?

-Progestin only (levonorgestrel) (Plan B, Plan B One-Step, Fallback Solo, among others)

In a strangulation victim what signs or symptoms of laryngotracheal injury should trigger intubation?

-Progressive hoarseness, stridor, and difficulty swallowing are consistent with advancing airway compromise and should trigger intubation.

How does Rheumatoid arthritis present?

-Progressive polyarticular symmetric arthritis -Accompanied by fever, weakness, and fatigue. -Swelling in the MP and PIP joints of the hand -Hvae morning stiffness lasting more than an hour. -Absence of DIP involvement in the hands helps distinguish RA from OA.

What are 3 indications for emergent surgical consultation with hemorrhoids?

-Prolapsed and nonreducible internal hemorrhoids -Hemorrhoids with severe bleeding -Hemorrhoids with intractable pain

What are risk factors for endometrial cancer?

-Prolonged exposure to high levels of estrogen and a thickened endometrium increase risk, so following are risk factors: -Obesity -Nulliparity (no births) -Longer period of fertility (early menarche/late menopause) -Anovulatory cycles -Obese women have high levels of endogenous estrogen

What are characteristics of nephrotic syndrome?

-Proteinuria leading to generalized edema -Increased risk of infections -Hyperlipidemia -Increased thromboembolic disease. (Liver attempts to counter the loss of albumin by increasing protein production of all kinds, including lipoproteins, leading to hyperlipidemia and hypercoagulability.)

What is common presentation of patient with myasthenia gravis?

-Proximal muscle weakness -Ptosis -Double vision

What are the locations for intraosseous line placement?

-Proximal tibia -Proximal humeral head -Distal femur -Medial malleolus -Iliac spine.

In the Le Fort classification system describing maxillary facial fractures what bone does each class of fractures involve?

-Pterygoid plate Le Fort fractures are fractures of the midface, which collectively involve separation of all or a portion of the midface from the skull base. T be separated from the skull base the pterygoid plates of the sphenoid bone need to be involved as these connect the midface to the sphenoid bone dorsally.

What can occur is scuba diver does a rapid uncontrolled ascent?

-Pulmonary Barotrauma = Pulmonary Over Pressurization Syndrome -"Burst lung" Must exhale on ascent to "vent" to prevent pop -Clinical presentation: -PTX -Pneumomediastinum -Pneumopericardium -Hemothorax from injured lung -Arterial gas embolism can occur (rarer)

What is the most common fatal injury to the chest in a primary blast injury?

-Pulmonary barotrauma

What injury is common and often severe with flail chest?

-Pulmonary contusion

What is the leading cause of morbidity and mortality among HIV-positive patients?

-Pulmonary infections

What are the clinical effects of hypothermia?

-Pulmonary: Increased risk for aspiration -CNS: AMS, incoordination, confusion, lethargy, coma -Renal: COLD DIURESIS and volume loss -Vascular: Hyperviscosity, thrombosis, DIC Pancreatitis -Cardiac: ***BRADYCARDIA and slow A-fib with OSBORN J waves with ***an idioventricular or junctional escape rhythm -Myocardial irritability (handle patient gently)

How do you dose atropine for OP poisoning? What receptor does it work on?

-Purely antimuscarinic drug that antagonizes excessive acetylcholine at muscarinic receptors. -Give liberally until respiratory secretions, bronchospasm, and cardiovascular instability are reversed. -Adults: For moderate to severe cholinergic toxicity, atropine should be administered beginning at a dose of 2 to 5 -Children: 0.05 mg/kg IV for children. If no effect is noted, the dose should be doubled every three to five minutes until pulmonary muscarinic signs and symptoms are alleviated -DOES NOT REVERSE respiratory paralysis that occurs from excess acetylcholine at nicotinic receptors. (2-PAM treats for this.)

What vascular lesions develops as a result of minor skin or mucosal trauma in about one third of patients, most commonly in children, pregnant women, and younger adults?

-Pyogenic granuloma = Granuloma gravidarum = Lobular capillary hemangioma

If first-line agents (benzodiazepines) don't resolve a neonatal seizure, consider ___________________ as the cause.

-Pyridoxine deficiency- an autosomal recessive issue. -Dose= Pyridoxine 100 mg IV -Check for low glucose in neonatal seizures - not as a cause, but as an effect.

How do you distinguish ST elevation of Ventricular Aneurysm from true STEMI?

-Q waves usually present (True STEMI doesn't have big Q waves) -Usually in anterior leads -Easily seen on echo -No reciprocal depression -No change from old ECG -No serial changes

What is treatment of Hypernatremia?

-RESTORE PLASMA VOLUME FIRST! TBW = Wt (kg) x 0.6 -Water deficit in liters = TBW x ( [current Na/ 140] -1) -Replace calculated water deficit over 48 hours -Start with NS NOT D5W May use diuretic to increase Na+ excretion -KNOW Target 0.5 mEq/hr correction -Too-rapid correction may result in cerebral edema

In child with bronchiolitis when do you get a CXR?

-Radiographynot needed in a child if the oxygen saturation level is above 92%.

What distinguishes disseminated gonococcus infection from other diseases?

-Radom migratory arthralgia & Dermatitis of dusky pustular lesions on the palms or soles or both followed by septic arthritis.

What is presentation of Tinea curis or jock itch and profile of patient?

-Raised, red plaques in the inguinal crease -Can spread to the buttocks, thighs, and perineum while sparing the genitalia -Erythematous, annular plaques with central clearing and sharp demarcated borders that might contain vesicles -Scrotum spared - Scrotum not involved -Men.

What are the most common behaviors associated with prescription abuse?

-Ranked by odds ratio -Specifically asking for the parenteral route -Reporting pain worse than 10 out of 10 -Making three visits in seven days -Having more than three different pain complaints -Claiming to have run out of medication -Requesting a certain drug by name -Noting a chief complaint of needing a medication refill -Reporting a lost or stolen medication

-Water hemlock (Cicuta maculata) poison: is characterized by ____________________?

-Rapid GI symptoms and convulsions, status epilepticus

Which is a cause of pneumomediastinum - A rapid ascent or rapid descent during diving?

-Rapid ascent: the volume of air within the lungs expands and causes barotrauma. -Rapid descent decreases the volume of air in the lungs, and does not cause barotrauma.

How does acute cyanide poisoning present?

-Rapid onset of coma -Apnea -Metabolic acidosis -Hypotension.

What are signs and sx's of Apathetic Thyrotoxicosis

-Rare - Elderly patients -Lethargy, slowed mentation, apathetic facies -Goiter present -Droopy eyelids -NO exophthalmos, stare or lid lag -Resting unexplained tachycardia -Resistant atrial fibrillation and CHF

What is pheochromocytoma & how is it diagnosed??

-Rare cause of treatable hypertension -Tumor of adrenal medulla cells (secretes norepinephrine) -Diagnosis: catecholamines and metabolites (VMA) in 24 hour urine

What is cause of intussusception in adults?

-Rare in adults -Usually secondary to malignancy that serves as a lead point for bowel obstruction

What are risk factors for mesenteric ischemia, and how do you diagnose it (what is best imaging test and lab test)? What is the physical exam finding in patients with mesenteric ischemia?

-Risk factors: dysrhythmias (Afib), low-flow (on digoxin or vasopressors) & hypercoagulable states, vascular disease Deadly disease of the elderly. -Diagnose with CT (thumbprinting sign), angiography -Lactate is best lab test! -Sudden onset with pain out of proportion to physical findings

What is risk of getting hep B from transfusion? What is risk of getting hep c or HIV from transfusion? What is most common contamination?

-Risk of hepatitis B is 1:200,000 - 500,000 -Risk of hepatitis C or HIV is 1:1-2,000,000 -Bacteria contamination is most common (usually Staph but not clinically significant.

What is concern in use of ketamine in patient with tracheal stenosis or tracheomalacia?

-Risk of laryngospasm may be greater in patients with anatomic abnormalities of the upper airway (eg, tracheal stenosis, tracheomalacia) -Risk also greater in those undergoing procedures involving significant or prolonged stimulation of the oropharynx.

Should you use succinylcholine or rocuronium in patient with h/o malignant hyperthermia? Why?

-Rocuronium. Patients with prior diagnosis of malignant hyperthermia should receive nondepolarizing neuromuscular blocking agents. -Succinylcholine is a known cause of malignant hyperthermia,

1 y/o child presents with macularpapular rash on his trunk. The day before he had presented for febrile seizure and was discharged home. What is the diagnosis?

-Roseola Infantum AKA Exanthem subitum -Febrile sz then as fever goes away rash pops up. Human herpes viruses (HHV) 6 Common at ages 6-18 months -High fever (3-4 days), then rash with defervescence -Febrile seizures are common -Pink macules and papules on trunk May spread to neck, face, extremities

What rash occurs in 6 months to 3 year/o is characterized by a high spiking fever that lasts 3 to 5 days then defervescence. Next is the sudden onset of a rash often described as pink and maculopapular that blanches to touch and is typically located on the neck, trunk, and buttocks and occasionally on the face and extremities? The rash normally fades after 2 days. Febrile seizures occur with this disease.

-Roseola infantum, or exanthema subitum

What are the following signs found in appy? Rovsing's sign: ? Psoas sign: ? Obturator sign: ?

-Rovsing's sign: LLQ palpation causes RLQ pain -Psoas sign: RLQ pain on thigh extension while lying in left lateral decubitus position -Obturator sign: RLQ pain with internal rotation of the flexed right thigh

What physical exam findings do you have with acute pericarditis?

-Rub (increased by leaning forward) -Tachycardia -Pulsus paradoxus (an exaggerated BP response to breathing - BP goes down on inspiration and up on expiration)

What pediatric disease has a rash that moves from head to toe with fever and soft palate petechiae, and has suboccipital, posterior auricular or posterior cervical lymphadenopathy?

-Rubella (German Measles - wimpy) -"3-day measles"

Patient presents with acute viral illness (fever, sore throat, headache) and prominent lymphadenopathy: posterior auricular, cervical, occipital and pink macules spread from face to feet. What is diagnosis?

-Rubella (German Measles) = wimpy mild measles -"Three day measles" -Part of Torch -1st trimester pregnancy (congenital defects)

6 Childhood rashes: Really Red Munchkins Scare Infected Chickens

-Rubella (German measles -wimpy) Rash any head and goes down, 3 day measles, lymphadenopathy -Roseola infantum (6th disease) (exanthema subitem) Fever, then truncal rash when fever is gone -Measles (rubeola) - Rash from head and goes down & the 3 C's -Scarlet fever (group A beta hemolytic strep) Strep throat with sand paper truncal rash -Erythema infectiosum (5th disease - 5 fingers slap face - slapped cheek) -Chicken Pox (Varicella) - Macules to papules to vesicles to crusted lesions Varying stages simultaneously

Patient presents with fever, cough, conjunctivitis, coryza (runny nose), tiny white spots on buccal mucosa, and maculopapular rash spreading from head to feet. What is diagnosis?

-Rubeola (Measles) the Real Measles, -Fever & 3C's -Fever, cough, conjunctivitis, coryza (3 "C"s) -Koplik spots: Buccal mucosa (before rash), non-tender, tiny white spots ("grains of salt") -Maculopapular, red-brown "morbilliform" rash SPREADS FROM HEAD TO FEET. -Complications: Encephalitis, pneumonia, otitis media, conjunctivitis

What is Premature Rupture of Membrane (PROM)? What special precautions do you take on exam, and what do you avoid? What 2 ways can you confirm PROM? What is disposition of patient?

-Rupture prior to onset of labor -Limit digital exams and use sterile gloves, Digital pelvic exams associated with increased risk -Sterile speculum exam (ferning) -AVOID doing bimanual exam Diagnosis: Examine vaginal fluid Nitrazine test: blue (positive) pH > 6.5 -Ferning -Complications -Premature labor, prolapsed cord, -infection (chorioamnionitis) -Admit

What is most common form of bacterial meningitis? What abx's do you give empirically? What medication do you give 15 minutest prior to the abx?

-S. pneumoniae (most common) & -N. meningitidis (college age) predominant causes >1 month -S. pneumoniae associated with highest morbidity/mortality Penicillin and ceftriaxone-resistant S. pneumoniae are prevalent. Add VANCOMYCIN empirically -Steroids first / then antibiotics in seriously ill patients or those with CSF WBC > 1000 / hpf -Dexamethasone 10mg IV q6h for 4 days in adults 15 minutes before or simultaneously with antibiotics

What's the most common source of pneumonia among persons who are HIV positive?

-S. pneumoniae is the most common cause of community-acquired pneumonia among BOTH immunocompetent and HIV-positive patients.

What are ECG changes associated with myopericarditis?

-S. tachycardia -Diffuse ST-segment elevation with PR-interval depression.

What is definition of hypertensive urgency?

-SBP ≥180 mmHg and/or DBP ≥110 mmHg -No signs or symptoms of acute organ damage

What are symptoms from exposure to organophosphorous compound (OP), which is used most commonly in insecticides?

-SLUDGE/BBB + Nicotinic effects(CNS) = cholinergic excess -Salivation -Lacrimation -Urinary incontinence -Diarrhea -Gastric Emesis -Bronchorrhea -Bronchospasm -Bradycardia -Nicotinic effects (Same as succinylcholine as depolarizing agent): -Fasciculations -Muscle weakness -Paralysis

What are 2 other Hematologic Sickle Cell Crisis in addition to vaso-occlusive crisis? What is 1st and 2nd most common cause of death in pediatric sicklers?

-SPLENIC sequestration 2nd most common cause of death in SCD children (infections are first, mostly pulmonary) -Sickled blood blocks splenic outflow = hypovolemic shock, -Painful hepatosplenomegaly -TX: with RBCs and exchange transfusion -APLASTIC crisis -Failure of bone marrow erythropoiesis -Reticulocyte count low -Precipitants: infection (parvovirus is the most common precipitant), ↓ folate -Self-limited

What are ST Segment Elevation Predictors of MI?

-ST elevation (horizontal or convex upwards) -Reciprocal ST depression -Changes over time - minutes to hours -May see hyperacute T waves (early)

What are the 3 modified Sgarbossa criteria in LBBB?

-ST segment elevation of 1 mm or more that is in the same direction (concordant) as the QRS complex in any lead -ST segment depression of 1 mm or more in any lead from V1 to V3 - ≥ 1 lead anywhere with ≥ 1 mm STE and proportionally excessive discordant STE, as defined by ≥ 25% of the depth of the preceding S-wave.

What are the ECG changes associated with LV aneurysm?

-ST-segment elevation in the anterior leads (V1-V5) with accompanying Q waves. See photo. -ST-segment elevation of MI is more frequently convex compared to concave changes seen in pericarditis, LV aneurysm, and left ventricular hypertrophy. Photo shows LVA of left and STEMI on right.

Hyperkalemia Treatment

-STABILIZE: Calcium gluconate 10% (10-20 mL) antagonizes the effects of high K+,, especially cardiac Membrane stabilizer: Quick onset, shortest acting -SHIFT: -D50 + insulin, bicarbonate, beta agonists Shift K+ extracellular to intracellular -REMOVE -Diuretics -Exchange resins polystyrene (Kayexalate) to remove K+ (consider risks) RISK OF INTESTINAL NECROSIS, so avoid in patient with slow motility -Dialysis if renal failure or treatment fails DON'T USE CALCIUM IN HYPERKALEMIA with DIGITALIS TOXICITY! → cardiac arrest

What is presentation of hypercalcemia?

-STONES, BONES, MOANS (psych) and GROANS (abdominal) -Neuro: AMS, WEAKNESS, hyporeflexia Increased nerve and muscle resting membrane potentials (Altered, Weak with short QT) -EKG: SHORT QT, BBB, heart block -Renal: POLYURIA, POLYDIPSIA, nephrogenic DI, calculi -GI: ABDOMINAL PAIN, nausea, constipation PUD, pancreatitis -Skeletal: BONE PAIN / fractures Metastatic calcifications

-Prone sleeping -Sleeping on a soft surface -Maternal smoking during or after pregnancy -Overheating from heavy bedding or clothing -Late or no prenatal care -Young maternal age -Prematurity, low birth weight -Male sex All the above are risk factors for ___________.

-SUID -More common among black and Native American infants.

Child presents with sore throat, fever, headache, vomiting. She has a sandpaper rash in flexor creases which moves to trunk and extremities; circumoral sparing Her tongue is bright red with bumps. -She also has antecubital Pastia's lines and skin peeling of palms and soles. What is diagnosis?

-Scarlet Fever -Group A beta hemolytic Strep toxin Sore throat, fever, headache, vomiting Sandpaper rash starts on flexor creases and moves to trunk and extremities; circumoral sparing "Strawberry" tongue Groin, axilla, antecubital areas (Pastia's lines think micropetechiae in these skin folds) Skin peeling (palms and soles Dx: Throat swab, increasing ASO titer -Tx: Pen G

Child has sandpaper rash of flexor surfaces with sparing of circumoral area and strawberry tongue, and: -Desquamation of hands & feet -Micropetechiae of axilla, groin, & antecubital area. What is the disease & how do you treat it?

-Scarlet fever -Caused by Group A Beta hemolytic strep -Micropetechiae = Pastia's lines -Pcn

What condition is associated with photophobia and severe boring pain. It presents with reddish or bluish discoloration from the inflamed scleral vessels within the edematous white outer coating of the eye.

-Scleritis - an inflammatory disorder of the sclera -Tx with NSAIDs and steroids.

What is profile of Squamous Cell Carcinoma?

-Second most common cutaneous malignancy -Elderly males with sun exposure, fair skin, Face, lips, ears, tongue, hands -Rapid growth, central ulcer, raised and indurated border -Metastases occur early TX: Excisional surgery, radiation

What are the causes of secondary adrenal failure and tertiary adrenal failure?

-Secondary adrenal failure = Due to hypopituitarism -Tertiary adrenal failure = most common cause overall = iatrogenic from prolonged steroid use

What stage of syphils is associated with a classic macular rash that involves the palms and soles, condyloma lata, lymphadenopathy, and fever, weakness, and body aches. This is the most infective stage because spirochetes are in the skin lesions.

-Secondary stage syphilis 6-8 weeks after contact.

Under what conditions do you see Hemorrhagic corpus luteum?

-Seen only in pregnant patients -A corpus luteum cyst occurs in early pregnancy and remains into 2nd trimester. -Can rupture and cause severe abdominal pain or bleeding which requires obstetrics consultation -Most commonly, when there is hemorrhage, it occurs within the cyst and does not commonly cause intraperitoneal bleeding or peritoneal signs.

What are signs and symptoms of posterior reversible encephalopathy syndrome (PRES)?

-Seizures (most common presenting sign) -Altered mental status -HTN -Vision changes.

What are Sengstaken-Blakemore tubes & Linton tubes used for ?

-Sengstaken-Blakemore tube - esophageal varices Need to know this for boards. -Linton tube - Gastric varices

What is the most common etiology of ARDS?

-Sepsis -Pneumonia is the most common condition in patients who develop ARDS, AND it also has one of the highest mortality rates.

What should be considered in any patient who is taking immunosuppressive drugs who presents with acute arthritis?

-Septic arthritis

What mode should the transvenous pacemaker should be set to, and how should the output dial be adjusted?

-Set to demand mode at 80 to 100 beats per minute -Output dial should be increased until capture. -Once capture is obtained, the output dial should be lowered until capture is lost, and then it should be set at 1.5 to 2 times the minimal threshold output required for capture.

Barotrauma from Diving = Disorders of descent. What are they?

-Squeeze Syndromes - any gas volume gets smaller - eg. Mask on face gets squeezed. -Barotitis Media: "Ear squeeze" Pain from pressure on the TM, due to inability to equalize pressure (blocked Eustachian tube) -TM can rupture with severe vertigo, N&V -Tx: Nasal decongestants, maneuvers to open Eustachian tube (Valsalva, et al.) -Other squeeze syndromes: -Sinus squeeze, -Facemask squeeze -Eye squeeze -Suit squeeze -Lung squeeze

What are the four stages of EKG changes for acute pericarditis?

-Stage 1: Diffuse ST elevation (does not correspond to coronary artery distribution) & PR segment depression - Concave upwards. -Stage 2: Normalizes - ST-segments and PR return to baseline - -Stage 3: T wave inversions -Stage 4: Normalization of EKG

What is CDC case definition of AIDS?

-Stage 3=AIDS=CD4 <200 -Opportunistic infections are unlikely with T-cell counts > 200 (therefore this number is important to know)

What is the predominant cause of pneumonia in cystic fibrosis?

-Staph aureus

What is impetigo?

-Staph. aureus, Strep. progenies -Highly contagious -Painless, honey-crusted lesions -Rarely causes glomerulonephritis -Tx: Dicloxacillin, cephalosporin, erythromycin, mupirocin ointment -Bullous impetigo = Staph infection

What is the most common bacterial cause of spinal epidural abscess?

-Staphylococcus aureus

What is the most common pathogen in bacterial tracheitis?

-Staphylococcus aureus

When treating infection of a tracheostomy stoma it is important to use broad-spectrum antibiotics to include coverage for what 3 most common infections?

-Staphylococcus aureus -Pseudomonas -Candida.

What is the most common causative pathogen in all types of infective endocarditis, and what is the antibiotic of choice?

-Staphylococcus aureus -Vancomycin is the most appropriate initial antibiotic choice for the emergency department treatment of suspected infective endocarditis. -Vanco also is the drug of choice for MRSA

What is the most common bacteria in septic arthritis?

-Staphylococcus aureus.

If you suspect giant cell arteritis, what must you do immediately and why?

-Start treatment with steroids immediately to prevent vision loss.

What is course of viral conjunctivitis, and how do you treat it?

-Starts in one eye then quickly spread to the other -Self-limited; Lasts 1 to 3 weeks - Supportive therapy only -Cool compresses, Diligent hand hygiene -Most contagious when discharge is present. -Patients should stay away from work, school, and daycare during that time.

How does rash start off in Henoch-Schönlein purport, what are associated symptoms?

-Starts off as a red and raised rash with an almost urticarial appearance and then progress to the classic purpuric, blue-purple coloration with bruising and tenderness. -Associated with joint pain or abdominal pain

What is presentation of hantavirus pulmonary syndrome?

-Starts out as a mild viral infection but is followed by severe pulmonary edema and myocardial depression.

What is Virchow's triad for DVT?

-Stasis -Hypercoagulability -Endothelial damage

What UA findings may occur in patient with Kawasaki's disease?

-Sterile pyuria caused by inflammation of the urethra.

What is Stevens-Johnson Syndrome?

-Stevens-Johnson Syndrome-part of spectrum of same disease with EM, TEN -Minor (erythema multiforme) → EM major (Stevens-Johnson) → EM maximum (TEN) -THINK Severe bullous form of EM -Mucosal involvement -Can be fatal -Bullous cutaneous lesions, mucositis, stomatitis, conjunctivitis, crusted nares -Children, adolescents, males -Severe reaction to medication: Sulfa, Sulfonamides PCN, barbiturates, phenytoin, tetracycline, thiazides

What is 1/2 life of warfarin if you stop taking it? What are the 4 ways of treating prolonged PT from warfarin, and what is advantage or disadvantage of each way?

-Stop the drug (2.5 day half-life) -IV vitamin K, 10mg, infused slowly, more rapid effect than oral on producing liver-based clotting factors / anaphylaxis in 3/100,000 cases -Give PCC - 4-factor prothrombin complex concentrate (II,VII,IX,X)(about $4,500) vs. FFP (about $250) -Fresh frozen plasma (10-15ml/kg), may result in: -Fluid overload -Requires defrosting -Time for infusion -2x's the adverse effects of PCC

What are clinical differences between Strep and staph TSS?

-Strep TSS - no rash. -Staph TSS: has following rash -Erythroderma or exfoliative dermatitis - a diffuse, macular, red/erythematous rash that resembles a painless but severe sunburn. -Desquamation between 1 and 3 weeks of symptom onset of the hands and feet. -Mucosal involvement is common. -Staph TSS- associated with retained foreign bodies (classically tampons) -Strep TSS is not.

What is the most common cause of pneumonia overall in both immunocompetent and immunocompromised patients?

-Strep pneumoniae

What is the most common bacterial organism in otitis media?

-Streptococcus pneumoniae, but most cases are viral.

What are most cases of bacterial meningitis among adults in the United States are caused by?

-Streptococcus pneumoniae.

What type of lightning strikes are there, and which ones the most serious?

-Strike types: -Direct (most serious) -Side flash -Contact strike (e.g. holding flag pole) -Ground current

What should be considered in any patient presenting with vertigo and ataxia?

-Stroke of the cerebellar artery -Posterior inferior cerebellar artery is the vessel most often associated with cerebellar infarcts and arises from the vertebral artery.

What is disorganized thinking?

-Tangentiality: Answers to questions are loosely related or unrelated -Derailment: Frequently switching from one topic to another -Word salad: Speech is so disorganized that it is incomprehensible

The rash of erythema multiforme is best described as discrete ________________________.

-Target lesions -Caused by: -Infection, such as herpes simplex virus -Drug (sulfonamides and other antibiotics, anticonvulsants) -Autoimmune disease -Idiopathic.

Between SDH and epidural hematoma which one is more common? Which has worse prognosis? What is the difference in CT finding for each one?

-Subdural hematoma -More common than epidural hematoma -Associated with bridging veins -Headache, ↓ mental status, trauma, elderly -May be acute, subacute or chronic -CT: Crescent shape -CT with contrast for subacute (may be isodense) -Worse prognosis than epidural -Epidural hematoma Trauma → brief LOC → lucid interval → headache, decreased mental status -Skull fracture, -MIDDLE MENINGEAL ARTERY INJURY -CT: Lens-shaped hematoma

Why do you avoid using succinylcholine in patients with OP poisoning?

-Succinylcholine is metabolized by acetylcholinesterase (which is inhibited by OP compounds) leading to exaggerated and prolonged neuromuscular blockade in poisoned patients. -Use non depolarizing paralytic like rocuronium.

How do you treat acute radiation proctitis?

-Sucralfate or glucocorticoid enemas (eg, hydrocortisone enema 100 mg twice daily)

What is Café coronary?

-Sudden cyanosis and collapse caused by food obstruction. Mistakenly thought to be from MI.

Asthma patients who increase their use of beta agonists are at higher risk of ________?

-Sudden death from asthma.

What sx's are associated with cerebellar infarcts? What is danger associated with cerebellar infarcts? What vessel most often associated with cerebellar infarcts?

-Sudden inability to walk or stand (drop attack) -Headache, nystagmus, ataxia, nausea, vomiting -Can present with only nausea and vomiting -Early neurosurgical consultation ***-Rapid deterioration with hemorrhage, infarct edema; Watch for respiratory arrest -Posterior inferior cerebellar artery.

What are the 5 classifications of burn injury?

-Superficial (aka 1st degree) Epidermis only (e.g. sunburn), no blisters, painful -Superficial partial-thickness (aka 2nd degree) Blister formation; moist, red, weeping Painful; blanches -Deep partial-thickness Blisters, wet or dry Does not blanch Sensation: Pressure only -Full thickness (aka 3rd degree) Waxy white, leathery Dry, inelastic, anesthetic Does not blanch -Deep tissue - 4th degree - muscle/bone

How do you treat cyanide toxicity?

-Supportive care -Skin and gastric decontamination -3 strategy antidote: 1) Binding of cyanide -Hydroxocobalamin, a precursor of vitamin B12, 2) Induction of methemoglobinemia - oxidation of the ferrous (Fe2+) in hemoglobin to the ferric (Fe3+) form. This provides an attractive alternative binding site for cyanide, in direct competition with site on the cytochrome complex. -When cyanide binds methemoglobin, a relatively less toxic cyanomethemoglobin is formed. -Use amyl nitrite or sodium nitrite to induce methemoglobinemia 3) Use of sulfur donors - maximize the availability of sulfur donors for rhodanese, a ubiquitous enzyme that detoxifies cyanide by transforming it to thiocyanate. -Thiocyanate is then renally excreted. -Sodium thiosulfate is the therapeutic sulfur donor of choice.

How do you treat strychnine poisoning?

-Supportive care, -Benzodiazepines and/or barbiturates -Airway control -Cooling -Hydration

What do you give and not give for myxedema coma?

-Supportive care: Rewarming, fluid support, search for underlying cause -GIVE IV THYROXINE (T4). May require large doses KNOW THIS. DO NOT GIVE IV T3 is not recommended (can cause V-tach) -Corticosteroids for possible adrenal or pituitary insufficiency

What is treatment for ACE-inhibitor-induced angioedema?

-Supportive treatment and airway protection is indicated. -NOT IgE mediated so the tx for allergic run/urticaria like antihistamines, steroids, and epi doesn't work.

What is the gold standard for diagnosing and treating necrotizing soft tissue infections?

-Surgical exploration

What is definitive treatment for intussusception in adults?

-Surgical resection -Barium or air contrast enema is used to treat intussusception in children but is unlikely to resolve bowel obstruction in adults due to other pathological etiologies.

What are swan neck and boutonnière deformities, and are they associated with RA or OA?

-Swan neck deformities, which are the result of increased extension of the PIP joint, are characteristic of RA, not OA. -Patients with RA can also have boutonniere deformities, an extension of the DIP joint caused by retraction of the extensor hood.

What are Thrombolytic Therapy Indications?

-Sx's greater than 30 minutes but less than 12 hours, not relieved by nitroglycerin -Has EKG criteria of STEMI: -STE in 2 contiguous leads -Posterior STEMI - Know this morphology -LBBB with Sgarbossa criteria -PCI delayed greater than 90-120 minutes

How does Guillain-Barre syndrome present?

-Symmetric ascending paralysis. -Frequently preceded by an upper respiratory or a diarrheal illness.

What's the management approach to acute cholecystitis in the emergency department?

-Symptomatic relief -Antibiotics -Surgical consultation.

What mode and how many joules do you use to convert the rhythm in an unstable pediatric patient in supraventricular tachycardia?

-Synchronized cardioversion at 0.5 to 1 J/kg

Unstable tachyarrhythmias, with the exception of multifocal atrial tachycardia, are typically treated with ___________. Unstable bradyarrhythmias are treated with __________________.

-Synchronized cardioversion. -Transcutaneous and/or transvenous pacing.

What is a frequent presentation of pulmonary hypertension?

-Syncope -Often related to dysrhythmia

What is Toxic Epidermal Necrolysis (TEN)?

-TEN-part of spectrum of same disease with EM & SJ. -Minor (erythema multiforme) → EM major (Stevens-Johnson) → EM maximum (TEN) -Affects >30% of BSA Peeling sheets of skin = +Nikolsky sign:Skin peels off with light pressure -Separation of dermal-epidermal junction Exposure to drugs, chemical agents, infections Sulfa, PCN, barbiturates, phenytoin, allopurinol, NSAIDs Mycoplasma, HSV Toxic patient, large bullae, mucous membranes, widespread systemic manifestations Death from Sepsis, pneumonia -Tx: Admit to ICU

What are the differences between 3 types of abortions?

-THREATENED Bleeding, pain -CLOSED os <20 weeks Vaginal rest, normal activities -INEVITABLE Bleeding -OPEN os <20 weeks D&C -INCOMPLETE Bleeding -TISSUE AT OS Products of conception D&C Includes 1st or 2nd trimester fetal demise or anembryonic gestation

What do you do when a patient has possible hepatitis B exposure from needle stick? What if source is HBsAg-positive?

-Test source for HB surface antigen -Test exposed patient for HB surface antibody -If exposed to HBsAg-positive source then: -If the healthcare worker is unvaccinated, give HBIG and start the vaccine series. If Vaccinated: -Incomplete series: give vaccine booster -If the healthcare worker has protective levels of antibody (>10 mIU/mL), no treatment is needed if low antibodies then give HBIG and vaccine booster.

10 y/o boy presents with painful right testicle. There is a blue dot on the testicle. What is dx? Do you need to call the surgeon?

-Testicular Appendage Torsion Twisting of appendix testis or other "non-essential" structures -More common in prepubertal boys -Blue dot sign: Necrotic appendages visualized through scrotum -Surgery is not necessary

What presents as a painless testicular mass that does not transilluminate on examination?

-Testicular cancer (a germ cell tumor)

Consider _______________ in any young male with abdominal pain.

-Testicular torsion

In an infant physical examination findings show right ventricular heave with a harsh systolic murmur and a single second heart sound. What is the diagnosis?

-Tetralogy of Fallot

What is the most common structural congenital heart disease occurring outside the neonatal period?

-Tetralogy of Fallot

What are De Winter's T waves?

-The De Winter ECG pattern is an anterior STEMI equivalent that presents WITHOUT obvious ST segment elevation. (THINK: ST depression and peaked T waves in the precordial leads.) =2% of acute LAD occlusions -Upsloping ST depression in the precordial leads (> 1mm at J-point). -Peaked anterior T waves (V2-6), with the ascending limb of the T wave commencing below the isoelectric baseline. -Subtle ST elevation in aVR > 0.5mm. -Absence of ST elevation in the precordial leads

What is Wernicke-Korsakoff syndrome?

-The best known neurologic complication of thiamine (vitamin B1) deficiency -Refers to 2 different syndromes, each a different stage of the disease. 1)Wernicke encephalopathy (WE) is an acute syndrome requiring emergent treatment to prevent death and neurologic morbidity. 2)Korsakoff syndrome (KS) refers to a chronic neurologic condition that usually occurs as a consequence of WE.

How is prognosis related to timing of onset of sx's after radiation exposure?

-The earlier the symptoms the worse the prognosis. Indicates a higher dose. -Doses over 1 Gy (gray) produce GI symptoms (N/V/D)

If a patient has recurrent symptoms within the first hour of TIA resolution, is this event classified as an infarct out TIA?

-The event would likely be classified as an infarct rather than as a TIA.

How has vaccination for S. pneumoniae, N. meningitidis, and Haemophilus influenzae type b affected incidence of meningitis?

-The incidence of meningitis caused by common pathogens has decreased because more people are getting vaccinations. -Vaccination rates for S. pneumoniae, N. meningitidis, and Haemophilus influenzae type b have led to decreased prevalence of infection overall.

What are the causes of Lactic Acidosis?

-The most common cause of metabolic acidosis -Causes: HYPOPERFUSION OR HYPOXIA -Medical conditions: SEIZURES, renal insufficiency, hepatic failure, infection, neoplasm (especially, leukemia, lymphoma and myeloma) -Drugs and toxins: Ethanol, TOXIC ALCOHOLS (also produce organic acidosis), METFORMIN (rare, associated with renal failure), ANTIRETROVIRALS -TOXIC ALCOHOLS -METFORMIN -ANTIRETROVIRALS

In an acute metabolic acidosis with normal respiratory compensation, what should the second two numbers of the pH be nearly equal to?

-The second two numbers of the pH should be nearly equal to the Pco2.

If you find a drowning victim in shock what should you think?

-There is NO SHOCK in drowning IF See shock in water then MUST R/O TRAUMA!

What is difference between drowning in Salt vs. fresh water?

-There is no significant survival effect.

At what temperature does the human body lose thermogenesis? What occurs to the oxyhemoglobin curve in hypothermia?

-Thermogenesis: Shivering thermogenesis is lost at 26oC, leading to rapid decompensation -Oxyhemoglobin curve shifts to the left, increasing oxygen binding of hemoglobin

What is problem with using the Phalen test and the Tinel sign to confirm the diagnosis of carpal tunnel syndrome?

-They are not very sensitive or specific -More specific finding is divided sensation of the fourth finger, with dysfunction on the radial aspect only.

What anti-hyperglycemias are associated with worsening CHF or MI's?

-Thiazolidinedione (Amanda = Rosiglitazone or Actosm= Pioglitazone) -Can worsen CHF -Associated with Acute MI (Avandia)

What is Bullous Pemphigoid?

-Think Chronic BBB , BIG BENIGN BULLOUS eruption. Autoimmune disease -Risk factors: Age > 60, female, malignancy, furosemide (Lasix) -Large bullae (2-5 cm) arise from erythematous skin -Mucus membranes INFREQUENTLY involved (-)Nikolsky sign negative IgE deposited on basement membrane Course is usually benign. -Mortality much less than in pemphigus vulgarism

What is diabetes Insipidus & how does it present?

-Think Diabetes Insipidus = Opposite of SIADH -Lack ADH so pee like crazy. -Excess urination and increased thirst and fluid intake -Presents with polydipsia, polyuria -Lab: Dilute urine & concentrated serum (hypernatremic and hyperosmolar)

What is molluscum contagiosum?

-Think tiny papules with teeny belly button in it. -Viral infection of skin (poxvirus) -2-5 mm umbilicated, pink, dome-shaped papules, Autoinoculation: Common locations are face, trunk, extremities (children), groin and genitalia (adults). -Self-limited Transmission: Close personal contact, swimming pools. Sexual transmission.

A postmenopausal woman presents with vaginal bleeding. What do you have to r/o?

-Think uterine cancer.

Thyrotoxicosis / thyroid storm is associated with what metabolic abnormalities?

-Think: Everything goes up except cholesterol because you use it up - not real physiology, but a way to remember this. -Elevated free T4 level -Decreased TSH level -Hyperglycemia -Hypercalcemia -Elevated LFTs -Low cholesterol

Tina capitis = ______________ Tinea barbae = ______________ Kerion = ____________________ Tinea corporis = _____________________ Tinea pedis= ____________________

-Tinea = Dermatophytes = filamentous fungi that metabolize and subsist upon keratin in the skin, hair, and nails. -Tinea capitis = scalp, Bald, broken hair Scaly patch -Tinea barbae = beard -Kerion - big mass from T. Capitis don't I&D, loss of hair -Tinea corporis = ringworm - Non-hairy parts of the body, outward spreading, annular lesion, clear center -Tinea pedis = athlete's foot

What is first-line treatment of tinea versicolor?

-Tinea versicolor is really Pityriasis Versicolor -Malassezia fungus like seb derm dandruff, so tx as dandruff. TX: Selenium shampoo like dandruff, ketoconazole shampoo or cream -Topical selenium sulfide shampoo for 1 week. -Topical azoles also can be used.

In electrical injuries Voltage = current x Resistance, so with increasing resistance get increased heat. What tissues has the highest an lowest amount of resistance?

-Tissue resistance: nerve < blood < muscle < skin < tendon < fat < bone -Injury depends on current and tissue resistance -Increased injury severity with increased resistance

What is role of platelets?

-To agglutinate when not in the lumen of a blood vessel and release factors that trigger INTRINSIC limb of the clotting cascade

When bleeding is controlled with Sengstaken-Blakemore tube insertion, why should the esophageal balloon pressure should be reduced by 5 mm Hg every 3 hours down to a pressure of 25 mm Hg?

-To avoid pressure necrosis

Why do you get an ECG in the evaluation of Kawasaki disease?

-To look for myocarditis and pericarditis

What are risk factors for bladder cancer?

-Tobacco use -Analgesic abuse -Pelvic radiation -Chemicals - Cyclophosphamide - antineoplastic agent

What is cause of Hypernatremia, and who does it occur in?

-Too little water relative to Na+ -Most commonly due to free water loss or decreased intake -Infants and debilitated elderly (limited access to water or impaired thirst) -Also seen with elevated aldosterone levels or diabetes insipidus

How do you treat tine curries or jock itch?

-Topical azoles -Keep skin clean and dry

Before attempting any nasal foreign body removal technique, what 2 items do you apply?

-Topical lidocaine and a vasoconstrictor such as phenylephrine -Reduces patient discomfort and helps make the attempt successful

What is second-line treatment for anal fissure when first line treatment doesn't work?

-Topical lidocaine gel to relieve pain -Calcium channel blocker in gel preparation to relax smooth muscle and decreases anal pressure

Patient with nasal packing for epistaxis presents with fever, hypotension, rash, and renal failure, liver failure, and altered mental status. Rash: Diffuse, erythematous, nonpruritic, macular Involvement of at least three systems What is diagnosis and treatment?

-Toxic Shock Syndrome -Staph aureus exotoxin -Prolonged tampon use, packed surgical wounds, nasal packing Menstruating females, postpartum, also in males -Think Fever, hypotension, rash and organ involvement -Rash: Diffuse, erythematous, nonpruritic, macular -Involvement of at least 3 systems Renal, hepatic, hematologic, GI, musculoskeletal, mucosal, CNS -Tx: IVF, remove source, antibiotics

What are the concerning clinical signs for necrotizing enterocolitis?

-Toxic appearance -Lethargy/somnolence -Distended abdomen -Hematochezia.

Plain abdominal radiography shows a long dilated segment of colon, a loss of haustra, and "thumbprinting," which represents submucosal edema and hemorrhage. What pathology is this?

-Toxic megacolon -Although both Crohns and ulcerative colits can lead to toxic megacolon, this progression is thought to be more prominent with ulcerative colitis.

-What is the most common cause of encephalitis in AIDS patients? It is also the most common CNS mass lesion in AIDS.

-Toxoplasmosis -protozoan (hosted by cats) infection usually caused by ingestion of undercooked meats (lamb and pork) -Most common cause of encephalitis in AIDS patients -T-cells <50 -Headache, confusion, altered mental status, fever, seizures -Diagnosis: CT (ring-enhancing lesions) -Tx: pyrimethamine, sulfadiazine

Is routine intubation with endotracheal suctioning the recommendation for meconium-stained baby?

-Tracheal suctioning should be performed only on a meconium-stained newborn with respiratory depression.

What are the 4 indications for nasogastric aspiration

-Transdiaphragmatic stomach herniation -Gastric decompression (obstruction/perforation) -Give medication or contrast Intractable vomiting -UGI bleeding

In otherwise healthy patient with active GI bleeding or trauma at what level of platelets warrants transfusion?

-Transfuse platelets for <50,000 /mm3 in patients with trauma or active bleeding

In mva, a patient with upper extremity hypertension, decreased pulses in the lower extremities, systolic murmur, deceleration mechanism with steering column damage - is suspicious for _________________.

-Traumatic aortic dissection.

What condition is characterized by: -Deep, aching eye pain -Decreased visual acuity -Injection of the limbus of the affected eye -Both direct and consensual photophobia -Cells and flare in the anterior chamber.

-Traumatic iritis -Blunt trauma to the globe may cause traumatic iritis. -Treatment: -Topical cycloplegia agents -Oral pain medications

If you're treating a patient who has just returned from a developing country with fever, cramps, nausea, and loose, nonbloody diarrhea, think _____________________.

-Traveler's diarrhea. -Self-limited disease caused by bacteria -Safely treated with a single-dose antimicrobial and an antimotility agent loperamide.

What is treatment for acute pericarditis?

-Treat underlying cause if possible -ASA, NSAIDs, colchicine; no steroids in the ED

How do you treat first-degree burns?

-Treated as outpatient with: 1) Cooling the skin immediately using tap water or cool compress (but not ice) 2) NSAIDs 3) Aloe vera -Occlusive dressing is not indicated. -Silver sulfadiazine is not indicated.

50 y/o female c/o "Electric", brief, intermittent attacks of Facial pain. Neuro exam is normal What is DX and TX?

-Trigeminal Neuralgia (Tic Douloureux) -Facial pain -Compression of trigeminal nerve (r/o MS) Middle age, women > men "Electric", brief, intermittent attacks of pain Neuro exam is normal -TX: Carbamazepine, surgical decompression

What is treatment for pneumocystis pneumonia?

-Trimethoprim-sulfamethoxazole for 21 days.

True or False? The clinical effects of marijuana come on more slowly when users ingest it rather than smoke it.

-True

True or false? Infants with pertussis might have a history of apneic episodes as their only symptom, and they rarely "whoop."

-True

True or False? A positive result on a urine drugs of abuse screen for cannabinoids or other drugs does not equate with intoxication from that drug.

-True. Confirms potential exposure not intoxication. -With chronic use cannabinoids can be detected up to 1 month following use

What are the signs and symptoms and treatment for Cushing's syndrome?

-Truncal obesity -HTN -Hirsutism -Moon facies -Buffalo hump -Purple striae Lab: glycosuria, ↑Na+ Tx: Stop steroids, treat cause

How do you tx tachycardia WPW?

-Tx based on QRS width -Narrow-complex regular tachycardia Treat like SVT -Wide-complex regular tachycardia Treat like VTach

What is the most common primary blast injury?

-Tympanic membrane perforation.

What is the Stanford classification for aortic dissection?

-Type A: ASCENDING = surgical treatment, any dissection which involves ascending aorta -Type B: DESCENDING/TRANSVERSE aorta only (primarily medical management)

There are 4 types of Blast Injury Classification. What is Type I blast injury? What are the top 4 organs injured in Type I Blast injuries?

-Type I = Pulse of pressure (barotrauma) -Ear: TM rupture(most common), ossicle disruption -Lung: Pneumothorax, air emboli -GI: Hollow viscus rupture -CNS: Concussion, air emboli

What is a cause of painless massive lower GI bleeding? What cause of lower GI bleeding is associated with HTN and aortic stenosis?

-UGIB- most common cause -Diverticulosis (painless, can be massive) -Angiodysplasia (AV malformations) -Associated with hypertension and aortic stenosis -Cancer/polyps -Rectal disease -Inflammatory bowel disease Aortoenteric fistula- Consider this if have aorta graft. Erosion of synthetic vascular graft into gut (often preceded by premonitory bleed → prompt surgical consultation)

What is definition and sign's of upper motor neuron lesion? What is definition and sign's of lower motor neuron lesion?

-UPPER (CNS/cord) Definition -Lesion above the anterior horn cells of the spinal cord or the motor nuclei of the cranial nerves -Manifestations: ***-Hyperreflexia ***-Clonus- involuntary and rhythmic muscle contractions on ankle reflex ***_-Babinski's sign-after the sole of the foot has been firmly stroked. The big toe then moves upward or toward the top surface of the foot. The other toes fan out. -LOWER (Peripheral Nerve) Definition -Lesion from the anterior horn cells to the muscles -Manifestations ***-Hyporeflexia ***-Weakness -Atrophy -Fasciculations

What diluent should you use for PRBC's?

-USE ONLY NORMAL SALINE for RBCs -Calcium in Ringer's lactate causes microclots to form so, saline is preferred

What is the imaging modality of choice to diagnose acute cholecystitis?

-Ultrasonography

What is diagnostic imaging study of choice for gallbladder? What is most accurate study for detecting cholecystitis?

-Ultrasound is the diagnostic study of choice (shows stones, wall thickening, duct dilatation, sonographic Murphy's sign, but not inflammation) -HIDA scan is a more accurate for cholecystitis, ultrasound better for detecting stones

What are the sign's and sx's or dx of items below? -Uncal herniation: ? -Cushing reflex: ? -Intracerebral stroke: Gaze ____________ lesion -Seizure disorder: Gaze _______________ seizure focus -Ophthalmoplegic migraine:? -Headache upon awakening: ?

-Uncal herniation: Ipsilateral fixed, dilated pupil, contralateral hemiparesis rapid deterioration -Cushing reflex: BP up, HR down, respiratory depression (late sign of elevated ICP, sign of impending herniation) -Intracerebral stroke: Gaze toward side of lesion -Seizure disorder: Gaze away from seizure focus (Think in sz the arms flail away from you, so you gaze away from lesion.) -Ophthalmoplegic migraine: Cranial nerve palsy 3,4, & 6 (III, IV, VI), mydriasis, diplopia, strabismus -Headache upon awakening: Hypoxia (COPD), ***mass, glaucoma, ***cluster headache, ***pseudotumor cerebri (idiopathic intracranial hypertension)

What type of patients get Alcoholic ketoacidosis, and what symptoms do they present with?

-Undernourished alcoholics who have recently binged on alcohol and have had limited food intake. - Present with Abdominal pain and vomiting -Intoxication is NOT typical.

What is the presentation of salivary gland stones (sialolithiasis)?

-Unilateral in presentation -Consist of calcium carbonate or calcium phosphate. -Usually in middle-aged men in submandibular gland.

To know the 5 types of kidney stones I attended UC-CSI school.

-Univ. of Calif CSI -Uric acid -Gout, radiolucent -Ca++ Oxalate #1 -IBD, diet -Cysteine - Staghorn, inborn error -Struvite = Staghorn, high pH -Indinivir =HIV

What are the 8 contraindications to gastric lavage?

-Unprotected airway -Hydrocarbon ingestion (unless intubated) -Corrosive ingestion -Foreign body ingestion -Bleeding diatheses -Esophageal strictures -History of gastric bypass surgery -Small children

EMTALA transfer requirements apply only to ___________ patients.

-Unstable

What unstable fracture are often misdiagnosed as a stable anterior wedge fracture in the setting of a fall or MVA?

-Unstable burst fractures -In one retrospective trial, 6 experienced radiologists correctly identified only 30 of 39 burst fractures among 53 thoracolumbar radiographs reviewed [43]. -Recommend CT if there vertebral compression > 50% or a burst fracture is suspected for any reason. -Spinal cord injury from retropulsion of bony fragments into the spinal canal can occur.

What is mortality of Listeria monocytogenes meningitis?

-Up to 40%.

How do you treat priapism for low flow(ischemia) vs high flow(arterial) causes?

-Urgent urologic consultation 1) All Low Flow: -Aspirating the blood from the corporal space then injecting an alpha-adrenergic agonist (sympathomimetic). -Phenylephrine: alpha-adrenergic agonist/sympathomimetic of choice. (minimal cardiovascular sided effects) -Sympathomimetic induces contraction of cavernous smooth muscle permitting venous outflow. -Transfusion for sickle cell disease) 2) High flow: -Embolization or surgery

When concerned for prostatitis should treatment be withheld if laboratory test results are normal?

-Urinalysis might be positive for leukocyte esterase, and the patient might have an elevated WBC count. -But diagnosis is a clinical one. -Treatment should NOT be withheld if laboratory test results are normal.

In Alcoholic Ketoacidosis why can you get false negative levels of ketones?

-Urinary ketones may be weakly positive or just negative. -Udip picks up A acid but not B acid - -The major and earliest ketone produced from fat breakdown is beta-hydroxybutyrate, but the lab-measured ketone is acetoacetate. Therefore, lab tests for ketones may be falsely negative.

In cauda equina syndrome, what is the most common presenting symptom?

-Urinary retention with or without resultant overflow urinary incontinence.

If you're treating an older man who has painless intermittent hematuria, consider_________________.

-Urinary tract cancer.

Can you use benzodiazepines in neonates for seizures?

-Used cautiously in neonates because of the higher chance for respiratory depression. -For neonates use Diazepam instead of lorazepam because diazepam has a shorter half-life.

C1 Inhibitor replacement protein is very useful for ______________angioedema, but not for _____________________ angioedema

-Useful for Hereditary angioedema. -NOT for

How do you treat PRES?

-Usual anti epileptic treatment: -Benzodiazepines -Fosphenytoin -Phenobarbital -HTN managed in the same way as hypertensive emergency: -IV calcium channel blockers or beta-blockers.

How do you distinguish ST elevation of Prinzmetal's angina/spasm from true STEMI?

-Usually no reciprocal depression

What is the most common gynecologic cancer? Of this gynecologic cancer what is the most common subtype? What is avg age for this type of cancer, and how does it present? What are the risk factors for this?

-Uterine Cancer -Adenocarcinoma most common type -Sarcoma (aggressive, worst prognosis) Average age 58 Risk: Continuous estrogen, obesity, diabetes, hypertension, nulliparity, early menses, late menopause -Abnormal bleeding, painless uterine -enlargement -Diagnosis: D&C or uterine biopsy

What is the cause of the majority of early postpartum hemorrhage?

-Uterine atony.

75 y/o woman complain of a pelvic pressure, worse with standing up or bearing down. The symptoms get better when she lies down. What does she have?

-Uterine prolapse -Risk factors: older women with high parity, obesity, and past surgery. -Treatment: f/u outpatient

When do you suspect endometriosis?

-Vague pelvic pain -Dysmenorrhea +/- dyspareunia -Absence of other objective findings.

What antibiotic do you use for spinal epidural abscess?

-Vancomycin to cover methicillin-resistant infection.

Child presents with fever, malaise, URI and Macules, papules → vesicles ("dewdrop on a rose petal") that come in crops → crusts

-Varicella (Chicken Pox) Varicella zoster virus Fever, malaise, URI -Macules, papules → vesicles ("dewdrop on a rose petal") that come in crops → crusts Complications (mostly adults): Pneumonia, encephalitis, otitis media, 2° infection -Tx: Acyclovir or analogues -AVOID ASPIRIN (Reye syndrome) -Prevention: Immune globulin if immunocompromised or pregnant, vaccine in kids and non-immune adults

What is profile of Dengue hemorrhagic fever?

-Vector: Mosquito - Viral infection in tropics and subtropics -Acute, self-limited fever, myalgias, headache, rash, lymphadenopathy, leukopenia

What is profile of West Nile virus?

-Vector: mosquito -Seasonal North American epidemic, from summer to fall with manifestations ranging from asymptomatic (80%) to viral encephalitis (1/150).

Condyloma Acuminatum is AKA ______________? What does this increase risk of?

-Venereal warts or anogenital warts -Spread by direct contact -Rectal, penile and perineal (most common) -***Increases risk of cervical carcinoma Need to rule out other STIs Tx: -Condylox (podofilox topical) -Aldara (imiquimod topical) -Cryotherapy -Vaccine available for prevention Indicated in adolescents

Post - arrest care tips:

-Ventilation goals: normoxia (pox low-mid 90s) and normocarbia -Target MAP > 65 mm Hg (Hypotension is bad) -Therapeutic hypothermia is good (goal temp??) -Urgent PCI for STEMI is good, consider for NSTEMI as well

Patient with h/o IVDA presents with back pain. What is DDX?

-Vertebral Osteomyelitis/Discitis -Epidural abscess

What is fourth finger sensory dysfunction on the radial aspect of the finger very specific for?

-Very specific for diagnosis of carpal tunnel syndrome

What kind of chemical weapon is mustard gas?

-Vesicant - an agent that causes blistering. -Dangerous as a liquid or gas -Enters the body through dermis or via respiration & reacts with water. -Causes large necrotic blisters on the dermis and mucus membranes. -WWI soldiers went blind b/c denudes eyeball.

What type of peripheral vertigo is associated with severe intermittent vertigo for a few days to weeks and associated with a viral syndrome?

-Vestibular neuritis - it is a viral infection. -Hearing is unaffected.

What is the most common cause of diarrhea? What is the most common cause of diarrhea in children?

-Viral (No blood or WBCs in stool) -Rotavirus -children

What is the most common cause of acute red eye?

-Viral conjunctivitis

When the do the Alcohol dehydrogenase and the specific cytochrome P45 enzymes convert to zero-order kinetics - a fixed amount per hour when metabolizing EOTH?

-When the enzymes become saturated, metabolism converts to zero-order kinetics - a fixed amount per hour. This is why alcoholics metabolize it faster. Ethanol metabolism kinetics FIRST-ORDER kinetics: -Ethanol metabolizes at a FIXED PERCENTAGE per hour -Low concentrations of ethanol -Persons who are not alcohol tolerant More common ZERO-ORDER kinetics -Ethanol metabolizes at a FIXED AMOUNT per hour -High concentrations of ethanol -Persons who are alcohol tolerant, chronic, alcoholics -Less common

In what group of people is the largest suicide rate?

-White Men > 75 years -Widowed men at greatest risk -Females attempt more often Males succeed more often

How do you treat traveler's diarrhea?

-With a single dose of ciprofloxacin, 750 mg, and loperamide. (Tx E. Coli) -If having severe symptoms or if blood in the stool (dysentery), extend treatment for 3 days -For travelers returning from southeast Asia substitute azithromycin, 1,000 mg in a single dose for ciprofloxacin as first-line therapy (Tx Campylobacter)

Perimortem cesarean delivery should be performed only under what criteria?

-Within 4 to 5 minutes of maternal arrest. -Gestational age is > 24 weeks. -If fetus age unknown, uterine fundus can be palpated above the umbilicus. -Fetal heart tones must be present -CPR of the mother should continue during the procedure

When is a person who had a TIA at highest risk for stroke?

-Within the first 48 hours.

How does gender and age affect high altitude illness?

-Women and age >50 have a lower incidence

What does hyperventilation do for patients with acute traumatic brain injury?

-Worsens the prognosis

What is treatment for carpal tunnel syndrome?

-Wrist splint -NSAIDs. -Steroid injection for recurrent symptoms and possibly surgical decompression

Since 2010 FDA has approved 4 new anticoagulant drugs - 3 factor Xa inhibitors and 1 direct thrombin inhibitor. What are they, and what have all 4 of these anticoagulant agents been approved for the treatment and prevention of?

-Xa inhibitors: -Rivaroxaban (Xarelto) -Apixaban (Eliquis) -Edoxaban (Savaysa) Direct thrombin inhibitor: -Dabigatran (Pradaxa) -All 4 of these have been approved for the treatment and prevention of venous thromboembolism & nonvalvular atrial fibrillation.

Can imaging be used to rule out pneumocystis pneumonia?

-Xray findings are normal in up to 20% of patients with PCP; imaging alone should not be used to rule out the disease.

Is Stevens-Johnsons syndrome a life-threatening condition? How does it present?

-YES! Definitely life-threatening condition. -Target lesions -Bullae -On hands or soles -On mucous membranes -Full-thickness necrosis - < 30% total body surface area. -Caused by: -Drug reaction -Infections -Malignancy -Tx: -ICU or burn unit -Pain & infection control -Cessation of the offending agent.

What gram-negative anaerobic bacterium can mimic symptoms of appendicitis due to development of ileocecitis?

-Yersinia enterocolitica

A child ate pork, and then had fever, RLQ abdominal pain, and (often bloody) diarrhea. What does the child have?

-Yersinia enterocolitica -Treatment: supportive if uncomplicated, quinolones or TMP-SMX if complicated

Does dexamethasone given with initial antibiotic dose decrease mortality rates of adult patients with S. Pneumoniae meningitis?

-Yes

Should you get a chest xray in a patient who was in close to an explosion?

-Yes even for those without pulmonary symptoms, but especially those who have pulmonary complaints or tympanic membrane rupture

Can pulmonary contusions occur without rib fractures?

-Yes in younger adults and children.

Is injury to the volar aspect of the digit is more serious than a dorsal injury?

-Yes! -Generally do well healing by secondary intention as long as the injury is < 1 cm.

Are there any EKG changes with aortic dissection?

-Yes! May show acute MI if dissection is proximal and involves coronary ostia -Up to 8% with Type A will have ST elevations

In a patient with acute GI bleeding who also has cirrhosis do you start antibiotic prophylaxis? Why or why not?

-Yes- start antibiotic prophylaxis. -Bacterial infections are present in up to 20 percent of patients with cirrhosis -Antibiotic prophylaxis is associated with: -reduced mortality rates -Decreased bacterial infection -Lowered risk of rebreeding -Shortened length of hospitalization. -Give ciprofloxacin 400 mg IV or ceftriaxone 1 g IV.

Do you treat asymptomatic bacteriuria and cystitis in all pregnant patients?

-Yes.

Is erythromycin ointment appropriate antibiotic selection for corneal abrasion if the patient did not wear contact lenses?

-Yes.

Should patients who present to the emergency department on the same day they experience a TIA generally be admitted to the hospital?

-Yes. -Expedited workup should include MRI, carotid assessment, telemetry monitoring, and possible echocardiogram.

Is nasogastric tube placement recommended in patients with hematemesis OR massive rectal bleeding with hemodynamic instability?

-Yes. NG tube placement is useful if it identifies a potential upper GI bleed,

Is Pneumocystis jirovecii a serious cause of pneumonia for HIV-infected patients?

-Yes. Pneumocystis jirovecii is a serious cause of pneumonia for HIV-infected patients, BUT it is still less common than infection with S. pneumoniae -Present only when the CD4 count<200. -Considered an AIDS-defining illness.

What don't you reduce a strangulated hernia in the emergency department?

-You will move necrotic bowel back into the peritoneal cavity causing sepsis or perforation.

What are the dx of the 2 patients below? 1) Clouding of consciousness -Severity fluctuates -Confusion -ACUTE, deteriorating course -Visual hallucinations -Abnormal vital signs 2) No clouding of consciousness -Decreased cognitive functioning -Decreased memory, judgment, personality -GRADUAL onset

1) Delirium 2) Dementia

What is profile of patient with cecal volvulus, and what is the plain film imaging sign, and what is treatment? Cecal volvulus is common cause of bowel obstruction in ____________________.

-Young females -ABRUPT pain -Imaging studies: -Plain upright abdominal X-ray: -"Kidney bean sign" -Cecum is displaced medially and superiorly, resulting in seeing small bowel in the right iliac fossa rather than large bowel. ***Cecal volvulus: common cause of bowel obstruction in pregnancy -Treatment: -Surgery

A 30 y/o obese non-pregnant female who has not had her menstrual period for 3 months presents with Idiopathic Intracranial Hypertension (Pseudotumor Cerebra). What finding do I see on fundoycopic exam? What CN palsy do such patients get? What are the CT head findings? What is treatment?

-Young, obese, female, ages 20-40 years, irregular menstrual cycles, amenorrhea -Nausea, vomiting, headaches, visual changes -Impaired CSF absorption -Elevated CSF pressure without mass or obstruction -Serious outcome: blindness, CN VI palsy know this -Papilledema, no focal signs -CT: "Slit-like" or normal ventricles, no mass effect -LP: High opening pressure TX: Repeated LPs, acetazolamide, weight loss, surgical shunt if severe and refractory

What is the Hutchinson sign, and what does it represent, and what should this prompt physician to examine?

-Zoster vesicles on the tip of the nose -Represents reactivation of the virus along the nasociliary branch of the trigeminal nerve. -Nasociliary branch also innervates the cornea and so should prompt the physician to evaluate the eye for herpes zoster ophthalmicus. -Treatment involves topical ophthalmic steroids in addition to antiviral medication.

How do direct thrombin inhibitors like Dabigatran, bivalirudin, argatroban adn desirudin affect aPTT & PT/INR?

-aPTT more than twice the upper limit of normal suggests excess bleeding risk -INR cannot be used to assess bleeding risk

Meniere Disease

-classic triad: -intermittent episodes of ear fullness -tinnitus -vertigo -Aural sx's

What are approved sites for IO insertion?

-distal tibia -Proximal tibia -Proximal humerus.

What is risk of acquiring HIV after percutaneous exposure? What increases risk of transmission?

0.3% = 30/10,000 Risk of transmission is increased when: - (VISIBLY) Contaminating device is VISIBLY contaminated with blood - (BLOOD VESSEL) A needle is placed directly into a BLOOD VESSEL vessel - (DEEP) Injury is DEEP -(HOLLOW needle)Contamination is with a HOLLOW bore needle -(HIGH VIRAL LOAD) Source is likely to have a heavy viral load (as occurs in terminal HIV) -Post-exposure prophylaxis recommended for above.

What are the 2 types of gangrene, and how do they differ in treatment?

1) Chronic dry gangrene -Necrotic tissue without secondary bacterial infection -Not a surgical emergency -Tx with protective dressings. 2) Wet gangrene - infection of gangrenous tissue and is a surgical emergency. -Tx: broad-spectrum antibiotics and prompt surgical consultation.

What are the 4 methods of cooling hyperthermic patient? What is NOT recommended?

1) Conduction (increasing the temperature gradient between the skin and the environment) Cold water immersion / ice slush / cooling blanket 2)Evaporation (increasing the gradient of water vapor pressure between the skin and the environment) Spray atomized cold water on the skin 3)Convection via fanning (increasing the velocity of air next to the skin) 4)Radiation (do not cover the patient) Immersion generally is NOT recommended

What are the 4 causes of low platelet counts?

1) DECREASED PRODUCTION: Aplastic anemia (WBCs, RBCs & platelets) viral infections / drugs (ethanol, thiazides, estrogens, chemotherapy drugs, heparin) 2) INCREASED DESTRUCTION: ITP / TTP / HUS / DIC / viruses / drugs (heparin) 3) SPLENIC SEQUESTRATION: -Hypersplenism (enlarged, overactive spleen rapidly and prematurely destroying RBCs and platelets) Enlarged spleen can hold half of blood volume and 90% of platelets 4) PLATELET LOSS - bleeding / hemodialysis Misc: -Malaria, rheumatoid arthritis, TB

What 2 elements do you use to pinpoint spinal level of pathology in low back pain?

1) Deep tendon reflexes 2) Skin dermatomes. -DTR's: -Biceps reflex tests C5-C6 -Triceps reflex - C7 -Patella reflex tests L2-L4 -Ankle jerk tests L5-S1 Cutaneous reflex: -Anal test S2-S -ck cauda equina Dermatomes: -C4: clavicle "C" is for "clavicle" -C6: thumb & index -Left hand "OK" sign makes a "6" with thumb and index -C7—Middle finger -C8: little finger -T4: nipple line "T" is for "thorax" -T10: umbilicus BellybutTEN -L1: inguinal ligament IL-L1 -L2-L4—Thigh into medial leg -L4: knee "Down on all fours" -Down on L4 -L5 dermatome runs along the lateral side of the leg and wraps around to include the toes. -S1 dermatome runs mostly along the back of the leg and wraps into the plantar surface of the foot. Lateral foot/ankle. Of note: -Herniating spinal discs press on the spinal levels above the level of origin (E.G. L5 herniated disc presses on spinal nerves from L4).

What are the five clinical features of psychosis?

1) Disorganized thinking 2) Delusions - fixed, incorrect belief held despite evidence to the contrary. Classified by theme, including persecutory, grandiose, and erotomanic. 3) Hallucinations - apparent perception of a stimulus that does not exist. Most commonly auditory in patients with schizophrenia 4) Negative symptoms 5) Disorganized or abnormal motor behavior. (Ranges from unpredictable agitation to catatonia)

What are the 4 steps for management of placental abruption?

1) Emergent OB consultation for possible imminent delivery if diagnosis is confirmed. 2) IV access 3) Send labs: -CBC -Coagulation panel -Fibrinogen level -Fibrin degradation product levels. 4) Fetal monitoring and monitoring of mother -Mother and fetus might decompensate quickly

What are the 3 types of normal physiologic ovarian cysts, and when do they occur in ovulation cycle?

1) Follicular cyst occurs first 2 weeks of menstrual cycle 2) Mittelschmerz: Transient ovulatory mid-cycle pain, unilateral, lasts <1day 3) Corpus luteal cyst occurs during last 2 weeks -Abdominal pain, bleeding, vomiting Tender adnexal mass, cervical motion tenderness Fluid in the cul-de-sac -Hemorrhage can occasionally cause shock and require emergent surgery -Diagnosis: *US, CT, laparoscopy

Confirming rupture of membranes has three components. What are they and which one is most specific?

1) Pooling of amniotic fluid in the vaginal vault 2) Positive nitrazine test result 3) Ferning revealed on microscopic analysis of amniotic fluid. occurs when amniotic fluid dries and sodium chloride crystals precipitate. -Ferning is the most specific.

What are the 3 general EKG indications for emergent reperfusion?

1) STE > 1 mm in 2 contiguous leads 2) Posterior MI (ST-depression with tall R-waves and upright Ts in V1-2) (Upside down STEMI) 3)LBBB with concordant Sgarbossa criteria a) ST-segment elevation measuring ≥1 mm concordant with the QRS in any lead. b) ST-segment depression measuring ≥1 mm in any of the V1 - V3 leads (concordant with the QRS).

What are the five features associated with malignancy in neck masses in infant?

1) Skin ulcer 2) Onset of the mass when neonate 3) Nonmobile, fixed to skin or fascia 4) Progressive enlargement 5) Size > 3 cm and hard

What are the two tests used to evaluate sciatica? Describe them, and what are the differences between them?

1) Straight leg raise, which is performed by lifting the leg affected by the radiating pain. 2) Crossed straight leg raise, which is performed on the opposite leg -Straight leg raise: -Patient lies on his back with the knee extended. -Examiner raises the affected leg up to 70 degrees. -Reproduction of low back pain AND radiation of pain down the posterior affected leg past the knee is a positive result. (Need both sx's. If just have back pain without radiation then test is not positive.) -Sensitive for a disc herniation but not specific. -Crossed straight leg raise test: -Perform the same test on the unaffected leg -Reproduction of low back pain AND radiation of pain down the posterior affected leg past the knee is considered a positive result. (Need both sx's. If just have back pain without radiation then test is not positive.) -Low sensitivity but high specificity (90%)

What are the 2 types of aortic dissection, and how are they managed differently?

1) Type A dissection (proximal dissection): -Involves ascending aorta -Requires emergent surgery. 2)Type B dissection: -Involves distal segment of thoracic aorta -Managed medically.

What is the triad of findings associated with Ramsay-Hunt syndrome?

1) Vesicles in the auditory canal 2) Unilateral facial paralysis 3) Ear pain. -Also called herpes zoster optics -Treatment involves oral steroids & antiviral medication.

What are the 3 Drowning Definitions?

1) WATER RESCUE: -No pulmonary findings -Submersion or immersion without evidence of respiratory impairment 2) NONFATAL DROWNING -Rescued from under water -Process of drowning interrupted 3) FATAL DROWNING -Death from drowning -NO OTHER DROWING TERMS JUST THESE 3 ABOVE

What are the 2 types of vertebrobasilar Artery stroke syndromes, and what are the presentations?

1) Wallenberg's syndrome -Vertebral artery thrombosis -Ataxia, vertigo, nystagmus, nausea, vomiting -Decreased pain and temperature sensation -Ipsilateral face and contralateral body -Ipsilateral Horner's syndrome (ptosis, miosis, anhidrosis) 2) "Locked-in" syndrome -Basilar artery occlusion at pons -Also seen with pontine hemorrhage, central pontine myelinolysis -Patient is awake and lucid, able to feel and understand -No motor activity except diaphragmatic breathing -Vertical eye movements are spared

What is sustained VT ?

> 30 seconds or if hemodynamic instability develops

Why shouldn't the nitrazine test be the only test used to confirm rupture of membranes?

A nitrazine test can yield a false-positive result for multiple reasons.

Who may perform the sexual assault forensic examination?

A physician or any other specially trained provider may perform the sexual assault forensic examination.

If patient does not meet or fails wait and see approach for otitis media what is the first-line treatment?

Amoxicillin (90 mg/kg/day PO for 5-10 days)

What is role of procainamide in patients with torsade de pointes?

Don't use procainamide in patients with torsade de points because it can further prolong QT interval.

Patient presents with ipsilateral facial paralysis, ear pain, and vesicles in the ear canal and ear lobe. What is the diagnosis?

Ramsay Hunt (Herpes zoster oticus): CN VII, zoster presenting with facial nerve palsy, ear pain -Think "Ramsay Hunt the 7th" -Triad: ipsilateral facial paralysis, ear pain, and vesicles in the auditory canal and auricle Complications: Pneumonia, meningitis, post-herpetic neuralgia, 2° infection, dissemination -Tx: Acyclovir and analogs, prednisone

What is the mnemonic to follow for emergency delivery of shoulder dystocia?

https://youtu.be/VIyHZyij0Bg HELPERRR -Help - call for help, OB doc and 5 assistants (1 for each leg, 1 to apply suprapubic pressure, 1 for meds) -E - Evaluate for episiotomy - Gives more room for inserting hands into vagina to perform maneuvers -L - Lift the legs - McRoberts maneuver. -P - Pressure to suprapubic area using CPR hand type pressure to posterior aspect of anterior shoulder. Apply in rhythmic or steady pressure. DON'T APPLY TO FUNDUS because further impacts shoulder dystocia -E - Enter vagina maneuver -Rubin - pushing posterior aspect of anterior shoulder with 2 fingers to push and slip shoulder under symphysis pubis -Woods Screw - Same as Rubin, but add other hand to place 2 fingers on anterior aspect of posterior shoulder and rotate. If this doesn't work then do reverse Woods screw rotating opposite direction. -For reverse Woods, now 2 fingers goes on anterior aspect of anterior should and 2 fingers to posterior aspect of posterior shoulder and rotate body. -R - 3 things - Remove posterior arm - insert my hand in vagina and press on antecubital fossa which flexes the arm then pull out or sweep across baby's chest and rotate baby out. -Roll patient to all 4's on hands and knees and repeat Rubin and Woods screw maneuvers -Rescue maneuvers - symphysiotomy - infiltrate suprapubic soft tissue then urethra is displaced laterally using the index and middle fingers placed against the posterior aspect of the symphysis, then use scalpel to incise through soft tissue and through 1/3 of pubic ligament, and the symphysis will pop open. -Zavanelli maneuver - flex baby's head rotate face to mother's sacrum, and push back into uterus and do crash c-section.

What is following periodontal ligament injury and features? Lateral luxation

—Displacement of the tooth from the socket in a lateral direction -If does not interfere with the bite (ie, permits full closure with normal interdigitation of the molars and the ability to chew food) may be observed. -Most instances, spontaneous repositioning will take place. -If interferes with biting then warrants repositioning, extraction, or urgent referral to a dentist.

What is following periodontal ligament injury and features? Subluxation

—Injury to the ligament or other supportive tissues, increased movement of the tooth but no displacement -Increased mobility and gingival bleeding at the base of the crown. -For both concussion & subluxation: -Treatment: soft diet until the child tolerates normal diet without pain. -Routine dental follow-up

What is following periodontal ligament injury and features? Concussion

—Pain to percussion or chewing but no increased mobility or displacement of the tooth -For both concussion & subluxation: -Treatment: soft diet until the child tolerates normal diet without pain. -Routine dental follow-up

What is following periodontal ligament injury and features? Extrusion

—Partially displaced dentition out of the bony socket - Refer to a dentist for immediate care ->3 mm displacement: Remove manually by the primary care provider by grasping the tooth with dry gauze and pulling if a dentist is not available immediately. Removal is essential when it poses an aspiration risk -<3 mm, then gentle repositioning may be performed

What are the 3 keys to the management of sepsis?

• Early recognition • Early antimicrobial therapy • Adequate IVF hydration