PaEasy Emergency Medicine, Emergency Medicine EOR Practice, Emergency Medicine EOR Exam, ER Final, ER

Testicular torsion occurs when the testis twists on the spermatic cord, causing venous outflow obstruction and eventual arterial occlusion. What is the most common deformity that predisposes a patient? What is generally the first imaging study? What is the definitive treatment?

"bell clapper" deformity; color Doppler ultrasound; surgical exploration

What does the AP and lateral neck radiographs show in patients with croup?

"steeple" sign - child may also have a mild leukocytosis -- Remember, PE shows a bark-like cough

What is the most common arbovirus in returning travelers?

#1 = Dengue fever #2 = Chikungunya

How do we treat narrow complex supraventricular tachyhardia?

*Adenosine 6mg push* Vagal stimulation Cardizem (diltiazem

5 H's:

-*H*ypovolemia -*H*ypoxia -*H*ydrogen ion (acidosis) -*H*ypo-/*H*yper*kalemia* -*H*ypothermia

Organophosphates Sxs: (SLUDGE)

-*S*alivation -*L*acrimation -*U*rination -*D*iarrhea -*G*astric cramping -*E*mesis

5 T's:

-*T*ension pneumothorax -*T*amponade (cardiac) -*T*oxins -*T*hrombosis (pulmonary) -*T*hrombosis (coronary)

Restrictive cardiomyopathy: often caused by a ____process, or post-radiation or post open-heart surgery. What is the most common first symptom?

--infiltrative process - amyloidosis, sarcoidosis, and hemochromatosis -- changes in myocardium --most common first symptom is exertion intolerance and fluid retention, signs of right heart failure

What test can be done to detect PROM (premature rupture of membranes)?

--nitrazine test detects pH of the fluid - alkaline if amniotic fluid --fern test detects crystallization of salts in the amniotic fluid

Tx for ankle fractures?

-3 sided splint (posterior splint) -Ortho consult

Football tackle, land on shoulder: -Injury likely?

-AC separation

What x-rays should you order for a shoulder dislocation?

-AP -Axillary -Y-view

What x-rays should be done on the knee when suspecting a patellar fracture?

-AP -Lateral -Sunrise

Pt on steroids to have surgery: -What could happen? -SSxs?

-Addisonian crisis -Weakness, anorexia

Tx for metabolic acidosis?

-Address underlying cause -Fluids and oxygen -Sodium bicarbonate (if pH < 7.2 or bicarb < 4)

What is included in the Primary Survey of a trauma incident?

-Airway (clear and protect airway) -Breathing (ventilate with 100% O2) -Circulation (skin color, cap reil, radial/femoral/carotid pulses) -Disability (mental status, glasgow coma scale, neuro exam) -Exposure (to visualize any hidden injuries)

Causes of hypomagnesemia?

-Alcoholism (MC) -DKA correction -Diarrhea -Diuretics -Pancreatitis -Cirrhosis

What information should obtain in a trauma incident?

-Allergies -Medications -Past medical history -Last meal -Events

What disorders are you concerned about in a elderly patient (>50 yrs old) with back pain?

-Aoratic Aneurysm -Fracture -Malignancy

What are the types of C1 injuries?

-Atlas fracture -Jefferson fracture

What is the classic triad for spinal infection (e.g., spinal epidural abscess or spondylitis)?

-Back pain -Fever -Neuro deficits

Seafood ciguatera illness: -MC from 3 animals? -Pathogneumonic Sxs? -Tx?

-Barracuda, Snapper, Grouper -Reverse Hot/Cold perception -Mannitol IV

Which nerve and arteries are commonly affected in humerus fractures?

-Brachial artery -Radial nerve

What is the classic pentad of Thrombotic Thrombocytopenic Purpura?

-CNS abnormalities -Renal disease -Fever -Microangiopathic hemolytic anemia -Thrombocytopenia

What are the causes of obstructive shock?

-Cardiac tamponade -Massive PE -Tension pneumothorax

Gastric Decontamination of Toxins: Charcoal not used for?

-Caustics (bleach) -Alcohol -Charged ions (Lithium) -Heavy metals (Iron, Lead)

Who is at risk for nonexertional heat stroke?

-Chronically ill or debilitated pts -Extremes of age (elderly, infants)

What are common complications of tibial fractures?

-Compartment syndrome -Peroneal nerve injury -Popliteal artery injury -Ligamentous injury

Tx for marine trauma (e.g., bit wound or puncture).

-Copious irrigation -Debridement -Leave lacerations open for delayed closure -Tetanus shot -Antihistamines or corticosteroids (for itching) -Submerge area in hot water if (catfish, lionfish, stingray, portugese man of war) -Abx only if infection suspected

Dehydration, hypotension, tachycardia, kussmaul respiration, N/V, abdominal pain, fruity breath, glucose > 250, anion gap metabolic acidosis, ketonemia. Dx and tx.

-DKA -Bolus Fluids until pt stabilizes (most important thing) -Potassium (if < 3.3) -Insulin -Phosphorous (prn) -Magnesium (prn) -Mannitol (if a child due to risk of cerebral edema)

What is diagnostic for anemia?

-Decreased RBC count -Decreased hemoglobin -Decreased hematocrit

What are the characteristics of 2nd degree frostbite?

-Deep skin freezing -Clear bullae -Numbness followed by aching/throbbing

Which animals are HIGH risk for rabies?

-Dogs -Foxes -Cat -Bats -Skunks -Raccoons -Cows

What is the classic triad of PE?

-Dyspnea -Pleuritic chest pain -Hemoptysis

Causes of hypothermia?

-Environmental exposure -Hypoglycemia -Hypothyroidism -Hypoadrenalism -Hypopituitarism -CNS dysfunction -Drug intoxication -Sepsis -Dermal disease

Most common causes of metabolic alkalosis?

-Excessive diuresis -Vomiting

When would you order plain radiographs for back pain?

-Extreme age (<18 or >50) -Hx of malignancy -Unexplained weight loss -Fever -Immunocompromised status -IV drug use -Recent trauma -Neurological deficits -Prolonged symptoms > 4-6 weeks

What is assessed in the Glasgow Coma Scale?

-Eye opening (1-4) -Verbal response (1-5) -Motor response (1-6)

Tx for mild hemophilia?

-FFP -Desmopressin -Factor 8 or 9 (depending on if A or B)

What factors are associated with increased risk of death from a major burn?

-Female -Elderly -Inhalation injury -Larger burn size

What is the diagnostic criteria for Toxic Shock Syndrome?

-Fever -Diffuse macular erythroderma rash -Desquamation 1-2 weeks after onset -Multisystem involvement (GI, muscular, renal, hepatic, CNS) -Lab negative except for Staph

What is the classical clinical triad of Rocky Mountain Spotted Fever?

-Fever -Rash -Hx of tick bite

What is the classic pentad of Leishmaniasis?

-Fever -Weight loss -Hepatosplenomegaly -Pancytopenia -Hypergammaglobulinemia

What are the four syndromes of severe arbovirus infection?

-Fever and myalgia -Arthritis and rash -Encephalitis -Hemorrhagic fever

Which groups of people are likely to suffer from mushroom poisoning?

-Foragers (purposely harvest mushrooms for food) -Teenagers (use it to get high) -Preschoolers (from playing outdoors) -Victims of homicide/suicide

What is a Maisonneuve fracture?

-Fracture of proximal fibula -Medial deltoid ligament sprain -Disruption of tibiofibular syndesmoses -Displaced medial malleolus (widened ankle medially)

What are the characteristics of 4th degree frostbite?

-Freezing deep to muscle, tendon, and bone -Mottled skin -Nonblanching cyanosis -Dry, black, mummified eschar

What are the characteristics of 3rd degree frostbite?

-Freezing of skin and subdermal plexus -Hemorrhagic bullae -Skin necrosis

What are the lab findings for DKA?

-Glucose > 250 -Bicarb < 15 -pH < 7.3 -Moderate ketonuria

What are the lab findings for HHS?

-Glucose > 600 -pH> 7.3 -Serum osmolality > 320 -Negative/slightly elevated ketones

What is the recommended method of tick removal?

-Grasp tick with forceps near point of attachment -Pull steady and with gentle traction

Individuals who often present with alcoholic ketoacidosis?

-Housewives -First time drinkers who haven't eaten anything (e.g., college kids) (NOTE: alcohol level is often LOW at time of presentation)

Causes of hypokalemia?

-Hyperaldosternoism -Alkalosis -Beta agonists -Insulin -Diuretics -Hypomagnesemia -Renal tubular acidosis -Vomiting -Diarrhea

What are the key features of DKA?

-Hyperglycemia -Ketonemia -Acidosis

Insomnia, shaky, ↑HR: -What should you suspect? -What lab value would confirm?

-Hyperthyroid -↓ TSH

What is Beck's Triad?

-Hypotension -Elevated JVP -Distant/muffled heart sounds (for cardiac tamponade)

What is the diagnostic criteria for Streptococcal Toxic Shock Syndrome?

-Hypotension -Multiorgan involvement (Renal, Liver, ARDS) -Group A strep on labs

Causes of increased platelet destruction?

-ITP -TTP -Hemolytic uremic syndrome -DIC -HELLP -Viral infections -Drugs

What is the tx for mushroom poisoning?

-IV hydration -Antiemetics -Diazepam (if hallucinating or agitation) -Atropine (if SLUDGE = Salivation, Lacrimation, Diarrhea, GI distress, Emesis)

Tx for Gila Monster bite?

-If reptile is still attached, place on solid surface to loosen its bite -Standard wound care -Search for implanted teeth

Tx for patients with back pain and progressive neurologic deficits?

-Immediate dexamethasone (prior to imaging) for suspected epidural compression -MRI

What are precipitating factors of erythema multiforme?

-Infections (e.g., herpes, mycoplasma) -Drugs (abx, anticonvulsants) -Malignancy

What is the progression from injury to death?

-Inflammation -SIRS -Shock -Multiorgan systemic failure

Tx for spine injuries?

-Inline cervical immobilization = 1st thing -High flow oxygen -High dose steroids (according to lecture, but book says not to do it) -Vasopressors if hypotensive shock -Neuro consult

Causes of hypernatremia?

-Lack of water intake -Excess water loss (e.g., vomiting, diarrhea, sweating) -Central Diabetes insipidus (not enough ADH) -Nephrogenic Diabetes inspidus (kidneys not responding to ADH) -Hyperthyroidism -Lithium

Brown Recluse Spider Bite: -Tissue damage? -Presentation?

-Local soft tissue necrosis -Erythematous halo around lesion

Causes of decreased platelet production?

-Marrow infiltration -Aplastic anemia -Drugs -Viral infections -Alcohol abuse

Causes of anion gap metabolic acidosis?

-Methanol -Uremia -Diabetic Ketoacidosis -Alcoholic Ketoacidosis -Paraldehyde -Iron -Isoniazid -Lactic acidosis -Ethylene glycol -Salicylates -Starvation

What reduction techniques can be used to reduce a shoulder dislocation?

-Modified hippocratic technique (traction + counter-traction) -Milch technique -Scapular manipulation technique -External rotation technique -Aronen technique

Tx for metabolic alkalosis?

-NS -Monitor electrolytes

What findings would confirm a diaphragmatic injury following trauma?

-Nasogastric tube coiled in thorax -Positive bowel sounds in the thoracic cavity

What are common complications of Galeazzi fracture?

-Nonunion, delayed union, malunion -Limited pronation or supination

Tx for sickle cell crisis?

-Oral rehydration -Opiates for pain -Oxygen

What is the tx for trauma during pregnancy?

-Oxygen -Fluids -Keep patient in left lateral decubitus position (or place wedge under right hip to avoid baby's supine hypotension syndrome) -Gastric intubation (to avoid aspiration) -Tetanus prophylaxis -Rho D immunoglobulin (for rh- mothers) Avoid vasopressors and tocolytics unless consulted with ob/gyn specialist

Tx of respiratory acidosis?

-Oxygen -Tx underlying cause of hypoventilation

Tx for bleeding disorder due to kidney disease?

-Packed RBCs -Desmopressin -Conjugated estrogen (last choice) -Cryoprecipitate (if life threatening)

What are the five classic signs of compartment syndrome?

-Pain out of proportion = most reliable indicator -Pallor -Paresthesias -Pulselessness -Paralysis

What are the characteristics of 1st degree frostbite (frostnip)?

-Partial thickness skin freezing -Erythema and edema -NO blisters or tissue loss

Cate Bite: -Infecting organism? -Antibiotic to use?

-Pasteurella multocia -Augmentin

When would you do a platelet transfusion?

-Platelet count < 10,000 -Platelet count < 50,000 + active bleeding

What are the types of C2 injuries?

-Posterior dislocation -Rotary subluxation injury -Hangman's fracture

What are the risk factors for PE?

-Pregnancy -Prolonged immobilization -OCPs -DVT -Hypercoagulable states

EKG changes with hypothermia?

-Prolonged PR, QRS, and QT -T-wave inversion -Osborn J wave (slow positive deflection at end of QRS)

What are the most common types of cancer causing back pain due to spreading to the vertebrae?

-Prostate -Breast -Kidney -Thyroid -Lung -Lymphoma

Tx for heparin-induced bleeding?

-Protamine -Stop heparin -Volume replacement

Tx for sprained ankle?

-Protection -Rest -Ice -Compression -Elevation If unstable = posterior splint + ortho referral

Pull on a kid's arm: -What injury is likely to occur? -Name of this injury?

-Radial head subluxation -Nursemaid's elbow

Tx for frostbite?

-Rapid rewarming in circulating water at 40-42 C -Topical aloe vera -Splint and elevate affected extremity -Update tetanus -Consult surgery before debridement

Tx for contact dermatitis?

-Remove offending agent -Aluminum acetate compresses -Hydroxyzine antihistamine -Hydrocortisone topical

What is the primary tx goal in hypovolemic shock?

-Restore normal cardiac output (e.g., pressors, fluids) -Stop bleeding or fluid loss

What conditions need to be monitored for in a person who sustains electrical injury?

-Rhabdomyolisis -Compartment syndrome -Renal failure

Which animals are LOW risk for rabies?

-Rodents (rats, squirrels, mice, chipmunks) -Lagomorphs (rabbits, hamsters)

What are the types of Distributive Shock?

-Septic shock -Neurogenic shock -Anaphylactic shock

What disorders are you concerned about in a young patient (<18 yrs old) with back pain?

-Spondylosis -Spondylolisthesis -Infection -Tumor -Developmental disorder

Tx for anemia?

-Stabilize -Tx underlying cause -Packed RBCs if symptomatic and unstable -Admit if ongoing blood loss

Which pathogens are involved in infective endocarditis?

-Strep viridians -Staph aureus = main one in IV drug users -Enterococcus -Staph epidermis = main one in prosthetic valves

Pneumonia w/ Rusty sputum: -Infectious organism? -Treatment?

-Strep. pneumonia -Azithromycin

Intermittent unilateral weakness: -What do you suspect? -What should you order?

-TIA -Carotid ultrasound

Tx for sunburn?

-Tepid bath -NSAIDs -Topic abx or blisters

How do you tx moderate/major thermal burns?

-Tetanus -100% O2 -Intubation and humidified oxygen if signs of airway burn -2 IV lines in unburned areas with fluids -Sterile DRY sheets (not wet sheets) to cover large burns -IV opiates

How do you tx mild thermal burns?

-Tetanus -Analgesics -Soap and water cleaning -Debridement -Topical neomycin or bacitracin -Follow-up in 24-48 hours

What are the causes of hypovolemic shock?

-Traumatic hemorrhage (fracture, exsanguination) -Non-traumatic hemorrhage (GI bleed, ectopic pregnancy rupture) -Volume loss (burns, vomiting, diarrhea, DKA)

Tx of respiratory alkalosis?

-Tx underlying cause -Lorazepam (if due to anxiety)

Causes of nonanion gap metabolic acidosis?

-Ureterostomy -Small bowel fistulas -Extra chloride -Diarrhea -Carbonic anyhydrase inhibitors -Adrenal insufficiency -Renal tubular acidosis -Pancreatic fistula

How does chlamydia present in women?

-Urethritis (usually dysuria at the END of peeing) -Cervicitis -PID -Infertility

How does chlamydia present in men?

-Urethritis (usually dysuria at the END of peeing) -Epididymitis -Orchitis -Proctitis -Reiter syndrome (urethritis, conjunctivitis, rash)

Causes of hypocalcemia?

-Vit D deficiency -Renal failure -Hyperphosphatemia -Hypomagnesemia -Hypoparathyroidism -Cimetidine -Pancreatitis

Tx for bleeding disorder due to liver disease?

-Vit K -FFP if active bleeding or before surgery -Desmopressin (can shorten bleeding time)

What is the order in which fluids and electrolytes should be corrected

-Volume -pH -K, Ca, Mg -Na, Cl

Tx for hypothermia?

-Warmed crystalloid IV -Remove wet clothing, dry, and recover pt -No therapy needed for sinus bradycardia or A-Fib (rewarming will fix it)

What EKG findings do you see in a PE?

-Wide/Weird S in lead 1 -Wide/Weird Q in lead 3 -Inverted/Weird T in lead 3

Diabetic Ketoacidosis: -Acid/Base disturbance? -Respiratory effect?

-↑ Anion Gap Metabolic Acidosis -↓ PaCO2 (normal = 35-45 mmHg)

What is the main goal of therapy for fluid resuscitation in burn patients?

0.5 to 1.0 mL/kg/hour of urine output

A 78-year-old woman with known diabetes mellitus type 2 is brought to the emergency room after a neighbor became concerned when newspapers began piling up on her doorstep and called the police. In the emergency department, she is found to be lethargic and disoriented, with tenting of the skin, sunken eyes, and dry mucous membranes. She is hypotensive and has a rapid pulse. She is wearing a diaper that apparently has been in place for several days, but is barely moist. What is the most appropriate fluid therapy for them to initiate? A 0.45% saline B 0.9% saline C 5% dextrose in water D 5% dextrose in 0.45% saline E Lactated Ringers

0.9% saline This woman is severely dehydrated so 0.9% saline is indicated. If she were less dehydrated, 0.45% saline (A) would be appropriate because of likely hyperosmolality. Once her glucose has dropped to 250 mg/dL, she should receive dextrose in water (C) or 0.45% saline (D) to prevent her glucose level from dropping too low. Lactated Ringers ı is contraindicated in patients who are likely to have severe acidosis or alkalosis.

What is the hallmark of pit viper envenomation?

1 or 2 fang marks with pain, erythema, ecchymosis, and edema

Etiology of Bacterial Meningitis in which age groups: 1. Strep pneumo; N Meningitis; H Flu 2. Group B Strep; E Coli; Listeria monocytogenes 3. Strep pneumo; Listeria monocytogenes

1. Ages 1 month - 50 years 2. neonates 3. >50 years or alcoholics

Wernicke's Encephalopathy -Triad of Sxs

1. Ataxia 2. Confusion 3. Eye paralysis

Pneumonia empiric treatment: 1. Augmentin, Macrolide (azithromycin, clarithromycin, erythromycin), doxycycline, second-generation cephalosporins ("a furry fox..") 2. Fluoroquinolone, ceftriaxone, cefotaxime. 3. Clindamycin, Pen G 4. Fluoroquinolone + Metronidazole, Ceftriaxone + metronidazole, Ticarcillan-Clav, Piperacillin-Tazo

1. CAP, inpatient 2. CAP, outpatient 3. Aspiration, community 4. Aspiration, hospital

Heat Stroke: 3 Hallmarks

1. Cerebral dysfxn w/ impaired consciousness 2. High fever 3. Absence of sweating

What are the three steps in determining acid base disorders?

1. Determine primary acidosis/alkalosis by looking at pH and CO2 and bicarb 2. Anion gap = Na - Cl - Bicarb. If > 20 (greater than 15 according to book) = primary anion gap metabolic acidosis 3. Bicarb + Anion gap - 12. If > 30 = underlying metabolic alkalosis If < 23 = nonanion gap metabolic acidosis

What are the 3 phases of Lyme Disease?

1. Erythema migrans rash 2. Annular red skin lesions, fever, lymphadenopathy, arthralgia, splenomegaly, facial nerve palsy 3. Chronic arthritis, myocarditis, encephalopathy, neuropathy

Known Drug OD: Check levels of 3

1. EtOH 2. Salicylate 3. Acetaminophen

What does it mean if a patient has the 1. HepB surface antigen/HBsAg 2. HepB surface antibody/ANTIHBs 3. Hep B antibody to core antigen/ANTIHBc

1. HBsAg - patient has Hep B infection 2. ANTIHBs - patient has been immunized or has recovered from acute infection 3. ANTIHBc - indicates an acute infection

The clinical dx of heat stroke is based on which three factors?

1. Heat stress 2. Hyperthermia (core temp > 40 C or 104 F) 3. Altered mental status

What are the four areas evaluated in the FAST exam?

1. Perihepatic region --- Morison pouch 2. Perisplenic region 3. Pericardium region 4. Pelvis - Douglas pouch

Unconscious pt: -Give 3 (in order)

1. Thiamine 2. Glucose 3. Naloxone

What is the NEXUS criteria?

1. absence of intoxication 2. absence of distracting injury 3. absence of midline cervical tenderness 4. absence of focal neurologic impairment

Stroke: Which vascular supply is affected with the following common manifestations? 1. contralateral extremity weakness - lower > upper; altered reasoning; bowel & bladder incontinence 2. contralateral face and arm weakness greater than leg; contralateral sensory deficits; dysphasia 3. contralateral visual field deficits; altered mentation; cortical blindness 4. vertigo/nystagmus; dysarthria; dysphagia; contralateral pain and temperature sensory deficits; syncope

1. anterior cerebral artery 2. middle cerebral artery 3. posterior cerebral artery 4. vertebrobasillar arteries

What are the adjunctive tx for fibrinolysis or PCI?

1. antiplatelets (ASA, clopidogrel) 2. anticoagulants (UFH, LMWH, DTI, direct factor Xai)

CSF Characteristics - Bacterial or Viral? 1. Opening pressure >300mmHg, >1000/microliter WBC; <40mg/dL of glucose 2. Opening pressure <300mmHg, <1000/microliter WBC; >40mg/dL of glucose

1. bacterial 2. viral

Atrial flutter - sawtooth pattern in II, III, aVF - what three treatments are used?

1. cardioversion if no contraindications 2. acute rate control tx w BB, CCB - amiodarone, sotalol, quinidine, or procainamide 3. If site of reentrant is known, catheter ablation

What is the pharmacologic therapy for heart failure?

1. diuretics for fluid retention 2. ACEi 3. vasodilators (hydralazine & nitrates) 4. BB for LV dysfunction 5. digitalis to increase cardiac contractility

What are the three strategies for reducing intraocular pressure in acute angle closure glaucoma? BY DEFINITION, IOP SHOULD BE ABOVE 20 mmHg.

1. increasing aqueous humor outflow - pilocarpine 2. inhibiting aqueous humor production/IOP - Timolol, Acetazolamide 3. reducing aqueous or vitreous humor volume - IV mannitol

Pediatric Fever Algorithm: 1. For babies ___in age and fever at ____; admit to hospital for blood cx, urine cx, lumbar puncture, possible CXR, IV Ampicillin & Gentamicin. 2. For children ___in age and fever at ___; do blood cx, urine cx, possible CXR, ceftriaxone 50mg/kg, d/c home if cx neg, follow up in 24 hr 3. For children ___in age and fever at ___; urine cx, possible CXR, stool culture; close follow up

1. less than 28 days old, temp >/=38C/100.4 2. 28 days to 3 months; temp >/=38C/100.4 3. 91 days to 3 years; non-toxic appearing; temp >/=39C/102.2, FULLY IMMUNIZED

Atrial fibrillation - regularly irregular - the most common sustained arrhythmia in adults - what three treatments are used?

1. rate control w BB, CCB, or digoxin 2. Anticoagulation w heparin & warfarin 3. rhythm control w amiodarone or cardioversion

What are the relative contraindications to thrombolytic therapy?

1. uncontrolled hypertension 2. previous CVA or intracranial pathology 3. noncompressible vascular punctures 4. prolonged CPR >10 minutes 5. pregnancy 6. active peptic ulcer disease 7. recent trauma within 2 weeks 8. major surgery within 3 weeks 9. recent internal bleeding within 2-4 weeks 10. current anticoagulation with INR 2-3 11. known bleeding diathesis 12. history of chronic severe hypertension 13. prior streptokinase allergic reaction (don't give streptokinase)

Timeline: Reperfusion should take place before ___hours of symptom onset. Door to needle time for fibrinolysis is ____min. Door to balloon time for PCI is ___min.

12; 30min; 90min

Stage 1 Hypertension is defined as greater than ____. Stage 2 Hypertension is defined as greater than ____.

140/90; 160/100

What is level of serum sodium shows hypernatremia? What equation is used to calculate fluid deficit?

145 (0.5 * body weight in kg)*(serum sodium/140)-1

What is the blood pressure in which tPA is excluded? What can be given to reduce blood pressure below this number so that tPA can be administered?

185/110; labetalol, nicardipine

A 23-year-old patient who has recently been on a ski trip presents with pain to the right hand after sustaining a fall. It is difficult to move, and there is pain on flexion of the digit. Based on this history what ligament would the patient most likely have injured? A 1st MCP joint ulnar collateral ligament B 2nd MCP joint ulnar collateral ligament C 3rd MCP joint ulnar collateral ligament D 4th MCP joint ulnar collateral ligament E 5th MCP joint ulnar collateral ligament

1st MCP joint ulnar collateral ligament The ulnar collateral ligament at the base of the thumb, or 1st MCP joint, is often injured in forced abduction, such as a fall while skiing or during other sporting activities. An injury to this ligament has traditionally been called Gamekeeper's Thumb, but the origin of this term referred to a more chronic injury sustained by English gamekeepers as a result of the way they killed rabbits using their hands. Any of the MCP joint ulnar collateral ligaments could be injured in a fall if the mechanism of injury creates significant forces on the ligaments, but the 1st MCP joint is far more commonly injured than the others mentioned above.

You are getting ready to evaluate a patient who has a past history of gout. The chief complaint is that the patients gout has flared up again, causing pain. Based on your knowledge of gout, which joint is most commonly the site of an initial gout attack? A 1st metatarsaphalangeal joint B Knee C Wrist D Elbow E Ankle

1st MTP joint A Eighty percent of gout attacks affect only one joint. The most common joint to be involved is the 1st metatarsal phalangeal joint. This common phenomenon is called podagra. Gout can affect other joints as well, including the knee, ankle and tarsal joints of the foot. Upper extremities are not commonly affected by gout. The knee is the most common joint to be affected by pseudogout followed by the wrist, MCP joints of the hands, hips, shoulders, elbows and spine

Viral Exanthems ___presents with cough, coryza, conjunctivitis, Koplik's spots, and a macular rash w head to toe progression. ___presents w strawberry tongue and sandpaper rash. Chest, arm pits, behind ears, and groin. ___presents with maculopapular rash that spreads from face, "3-day measles" - dangerous during pregnancy.

1st disease - measles 2nd disease - scarlet fever 3rd disease - german measles; rubella

What is the abx prophylaxis for open fractures?

1st gen cephalosporin (cefazolin) + aminoglycoside

What's the therapeutic INR for warfarin for most patients?

2-3

What percentage of volume loss causes hypovolemic shock?

20-30% volume loss

What is the normal range for Bicarbonate?

22-26

How long after MI can we expect CK-MB and Toponin I to elevate?

3 hours

tPA should be considered in patients presenting with ischemic strokes of less than ____ hours of symptom onset -- and without evidence of hemorrhage on CT of the head. What is the time for "expanding the window".

3 hours -- up to 4.5 hours according to AHA

Permanent neuronal injury can ensue within ____minutes of continuous seizure activity, even in the absence of apparent convulsions.

30-60

rH negative woman who is 14 weeks pregnant presents with vaginal bleeding and passage of clots. What amount of Rhogam is indicated for her?

300 ug 50 for less than 12, 300 for more than 12

What is the normal range for CO2?

35-45

Hypothermia is defined as a core body temperature less than ___. The risk of cardiac dysrhythmia does not occur until severe hypothermia ensues (less than 30/86). ____blebs are less favorable than clear blebs. Tx:

36/95F; Hemorrhagic: rapid active warming with circulating 37-40C water.

What is the 3 to 1 rule for fluid resuscitation?

3mL of crystalloid replacement for every 1mL of blood lost

What is the definition of shock?

4 things: -Inadequate delivery of oxygen -Insufficient circulation -Profound physiologic disturbances -Cellular hypoxia and vital organ dysfunction

Prostatitis can be acute bacterial, chronic bacterial, or chronic nonbacterial. For acute bacterial, fluoroquinolones or Bactrim are indicated for _____. For chronic bacterial, fluoroquinolone or Bactrim are indicated for ______.

4 weeks; 1-3 months

How long does it take before tissue necrosis after a high pressure pinpoint entry of foreign body?

4-12 hours

Dyspnea hx has what level of increased mortality with chest pain?

4X

What is the Parkland formula for fluid resuscitation in burn victims?

4mL/kg x %BSA burned. First half given over first 8 hours, second half over next 16 hours.

Patients in which of the following age groups are least likely to experience a dislocation or sprain when a significant stress is placed on their joints? A 5-10 years old B 15-20 years old C 35-40 years old D 55-60 years old E 75-80 years old

5 -10 yo Dislocations and ligamentous injuries are uncommon in prepubertal children as the ligaments and joints are quite strong as compared to the adjoining growth plates. Excessive force applied to a child's joint is more likely to cause a fracture through the growth plate than a dislocation or sprain.

What are the 5 levels of verbal response in the Glasgow Coma Scale?

5 = alert and oriented 4 = disorientated conversion 3 = speaking but nonsensical 2 = moans and unintelligble sounds 1 = no response

For synchronized cardioversion, use ____Joules for paroxysmal supraventricular tachycardia and _____Joules for a fib and VT.

50J, 100J

CDC guidelines for PPD result interpretation: 1. __mm or greater positive when a. HIV positive or who have HIV risk factors; b. recent close contact w TB; c. CXR w evidence of healed TB infex 2. __mm or greater positive when a. born in high prevalence area b. IV drug user C. low income population d. nursing home resident e. <age4 f. DM, malignancy, corticosteroid use, immunosuppression, renal failure. 3. __mm or greater is positive in all other cases.

5mm; 10mm; 15mm

Viral Exanthems 4th disease or Filatove Dukes disease is not considered a separate disease anymore. Thought to be a milder, variant form of scarlet fever. ___presents w flu-like illness and later lacey rash on arms & legs, "slapped cheeks". ___presents with high fever then defervescence then maculopapular rash; HHV6

5th disease or erythema infectiosum; 6th disease or roseola

What are the 6 levels of motor response in the Glasgow Coma Scale?

6 = follows commands 5 = localizes pain 4 = moves or withdraws to pain 3 = decorticate flexion 2 = decerebrate extension 1 = no response

Elevations of troponins are not reliable until after what time amount has elapsed?

6 hours

How long do you have in compartment syndrome before irreversible tissue damage?

6 hours (must do fasciotomy within 6 hours)

Alternating convergent strabismus is considered normal until what age in infants?

6 months

How long does it take before a lyme disease can be transmitted from a tick to a person?

72 hours (if attachment is less than this -> almost no risk of infection)

The presence of pulses may help to approximate the systolic blood pressure. Radial pulse present means ~ ____mmHg Femoral pulse present means ~ ____mmHg Carotid pulse present means ~ ____mmHg.

80, 70, 60

Hypotension is defined as a systolic blood pressure less than _____mm Hg or a decrease from baseline by more than 30mmHg. What are the 3 treatments for improving blood pressure?

90mmHg; 1. IV Fluids 2. Vasopressors - dopasmine, dobutamine (risk is aggravation of arrhythmias and increase myocardial oxygen demand) 3. intra-aortic balloon pump

A 21 year-old female presents to the emergency department after having a cast applied to her right arm earlier that day. Approximately one hour ago she began having extreme 10/10 pain in her right arm and is in visible distress. When considering the diagnosis of compartment syndrome, permanent damage to the muscle begins after how many hours of ischemia? A >2 hours B >6 hours C >8 hours D >12 hours E >24 hours

> 8 hrs Permanent damage results after >8 hours (C) of ischemia. Nerves begin to lose conduction within 2 hours of onset of elevated pressures. Neurapraxia can occur within 4 hours, and irreversible damage occurs 8 hours after elevated pressures. Functional impairment is unlikely when compartment syndrome is diagnosed and treated within 6 hours of its onset. While deficits can occur prior to 8 hours, permanent damage is usually not seen before 8 hours (A and B). After 12 or 24 hours, permanent damage has already resulted in most cases (D and E). The key to early detection of compartment syndrome is a high index of clinical suspicion.

A 50-year-old woman with a history of hypertension complains of chest tightness and dyspnea while walking up one flight of stairs. She recently experienced an episode of near-syncope. She denies a history or rheumatic fever. On auscultation, a crescendo-decrescendo systolic ejection murmur is heard at the upper right sternal border radiating to the carotids bilaterally. Given the patient's physical exam findings, which of the following is the most likely diagnosis? A Severe aortic stenosis secondary to congenital bicuspid aortic valve B Aortic regurgitation/insufficiency C Mitral stenosis D Aortic regurgitation/insufficiency E Tricuspid regurgitation/insufficiency

A Choice A is correct, as the murmur of aortic stenosis is usually described as a crescendo-decrescendo or systolic ejection murmur heard best at the right upper sternal border. In addition, the murmur of aortic stenosis is frequently transmitted to the carotid arteries. In a patient of this age, with symptoms suggestive of severe aortic stenosis and with these physical exam findings, a congenital bicuspid aortic valve is the best choice, especially as the patient denies a history or rheumatic fever, which is also a cause of developing aortic valve stenosis in individuals under the age of 65. Patients with a congenital bicuspid aortic valve typically develop symptoms once the valve leaflets have become calcified and thickened, secondary to the undue stress over many years on a structurally abnormal aortic valve. Choice B is incorrect, as the murmur of aortic regurgitation is usually described as a high-frequency decrescendo early diastolic murmur heard best at the left upper sternal border or at the right upper sternal border. Choice C is incorrect, as the murmur of mitral stenosis is described as a low-frequency rumbling diastolic murmur that is decrescendo in early diastole, but may become crescendo up to the first heart sound with moderately severe mitral stenosis and sinus rhythm. Choice E is incorrect, as the murmur of tricuspid regurgitation is described as a holosystolic descrescendo murmur.

A 22-year-old male hurts his right knee while playing football on artificial turf. He states that he planted his foot and went to turn, but his leg didn't turn with his body. He instantly felt a popping sensation in the knee. A few hours later he develops an effusion. Based on the history of the injury, which knee structure was likely injured? A Anterior cruciate ligament (ACL) B Lateral collateral ligament (LCL) C Medial collateral ligament (MCL) D Posterior cruciate ligament (PCL) E Quadriceps tendon

ACL A Non-impact rotational or hyperextension forces are the most common mechanisms for sustaining a tear of the ACL. One third of patients report hearing an audible popping sound as their ACL tear occurred. Because the ACL is a vascular structure, when it tears a rapid bloody effusion (hemarthrosis) usually develops which effects mobility of the joint. Lateral collateral ligaments are the least likely to be injured as the type of force necessary to cause injury would be a varus stress which is unlikely to occur in typical circumstances. Medial collateral ligament injuries are fairly common and produced by a valgus force that stresses the ligament. This can occur in many sporting events including those in which another competitor might fall on or dive into the lateral aspect of the knee. Trauma to a knee can result in tears of both the ACL and MCL in certain situations. A tear of the quadriceps tendon usually occurs when a person falls on a knee that is partially flexed. As the quadriceps muscle contract to prevent excessive flexion, the force and momentum of the fall may overwhelm the knee extension mechanism and cause the rupture. No such mechanism occurred in our scenario. Posterior cruciate injuries occur when the tibia is driven posterior in relation to the femur as may happen when a car dashboard is driven into the tibias during a major front impact collision. A powerful hyperextension force can result in both ACL and PCL tears (usually in that order). PCL tears are much more uncommon than ACL tears and don't generally occur with basic rotational forces as described in our patient scenario.

A popping sensation in the knee followed by significant swelling after running full speed and then coming to quick stop. Dx and tx.

ACL injury -Knee immobilization -Ortho follow-up

What is the most likely reason for a patient to have cardiogenic shock? A Acute myocardial infarction B Sepsis C Trauma D Aortic dissection E Pericardial effusion

AMI While trauma can account for a patient being subjected to cardiogenic shock, the overwhelming etiology for the shock comes from an MI.

The most common cause of ____is Strep pneumo, H flu, M cat and classic treatment is high dose amoxicillin - 80-90mg/kg/day

AOM - acute otitis media

What labs/imaging do we order to diagnose pancreatitis? What is te test of choice for splenic rupture

AXR showing sentinel loop sign and colon cutoff sign Pseudocytes on US CHOICE- CT

Pt presents with sudden, painful vision loss, redy eyes, and non reactive pupils. You suspect glaucoma...what pressure is indicated for glaucoma?

Above 21 mmhg

Fluctuant area of swelling, tenderness, and overlying erythema.

Abscess -I&D -Abx only needed if immunocompromised, systemic symptoms, abscess on hand or face

Dicloxacillin prophylaxis for pts at high risk of endocarditis is only indicated for which ER procedure?

Abscess drainage

A 23-year-old man presents to the outpatient clinic for follow-up from a recent urgent care visit. He complains of sore throat, fever, fatigue, myalgias, and a rash that started 5 days ago, and have worsened since he was seen in the urgent care 3 days ago. The patient appears non-toxic with a temperature of 39.4 degrees Celsius. Physical exam reveals pharyngeal and tonsillar erythema without exudates, generalized lymphadenopathy, a morbilliform rash on his trunk, and no hepatosplenomegaly. A rapid strep screen and Monospot performed at the local urgent care were reportedly negative. Which of the following prevention strategies should be recommended to this patient? A Abstain from sexual activity B Avoid aspirin C Avoid contact sports and rest D Bedrest and increased fluids E Take the full course of antibiotics

Abstain from sexual activity The patient presentation is consistent with acute retroviral syndrome. The patient is highly contagious and should be counseled on strategies to prevent transmission of HIV to others (A). Aspirin use in viral syndromes (B) is associated with Reye's syndrome, but most often occurs in children with influenza or varicella. Avoiding contact sports (C) is appropriate patient education for a patient with infectious mononucleosis, and patients with group A strep pharyngitis should be instructed to take the full course of their antibiotics (E).

Hip dislocations are often associated with what type of fracture?

Acetabular

Antidote → Acetaminophen

Acetylcysteine

Severe lower leg pain, unable to walk on toes, run, or climb stairs. Unable to plantar flex foot. Dx and tx.

Achilles tendon injury -Hang legs over side of bed and splint in that position

Chemical spilled on arm. Coagulation necrosis with eschar. Dx and tx.

Acid burn -Copious irrigation with water (UNLESS sodium, lithium, calcium, or magnesium metals -> Mineral oil) -Tetanus

Ground glass appearance of the cornea after something splashed in eye. Dx and tx.

Acid burn -Normal saline irrigation until pH is normal -Visual acuity check and pH testing AFTER 1-2 liters (do not do this before irrigation) -Consult ophthamology

Cystic acne with ulcerating lesions, fever, myalgia, and hepatosplenomegaly. Dx and tx.

Acne fulminans -Prednisone -Outpatient referral to dermatology

What is the definition of acute back pain, subacute back pain, chronic back pain?

Acute = pain < 6 weeks in duration Subacute = pain 6-12 weeks in duration Chronic = pain > 12 weeks in duration

Rapid ascent to higher elevation. Within a day, bifrontal headache, N/V, anorexia, fatigue, oliguria, postural hypotension, facial and peripheral edema, retinal hemorrhages. Normal O2 sat. Dx and tx.

Acute Mountain Sickness If mild: -NSAID or Tylenol -Odansetron If pulmonary edema, ataxia, or altered consciousness: -Immediate descent -Hyperbaric therapy -Acetazolamide + Dexamethasone

______presents with sudden onset of eye pain, blurred vision, h/a, n/v and they may report a "halo around lights".

Acute angle closure glaucoma - an increase in intraocular pressure and the potential for optic nerve injury

What type of patient is contraindicated for prostate exam by DRE?

Acute bacterial prostatitis because it may lead to speticemia

Sickle cell patient with chest pain, dyspnea, cough, and fever. Dx and tx.

Acute chest syndrome -Oral rehydration -Opiates for pain -Oxygen -Exchange transfusion (possibly)

TIMI and GRACE are scoring systems that stratify patients into risk levels of what? What is high risk cut offs for each score?

Acute coronary syndrome TIMI- greater than 5 GRACE- Greater than 119

Causes of Neurogenic Shock?

Acute injury to spinal cord

_____presents with abrupt onset of fatigue, malaise, bone pain, sweats, bleeding, and easy bruising. PE reveals pallor, petechiae, and ecchymoses.

Acute leukemia

A 66-year-old woman presents to the emergency department with a complaint of abdominal pain and distension for the past 3 days. Examination reveals a protuberant abdomen with diminished bowel sounds and tympany to percussion. Flat and upright abdominal radiographs reveal distended loops of bowel with prominent haustral markings. Which of the following etiologies is the most likely cause of the patient's condition? A Volvulus B Adenocarcinoma C Diverticular disease D Strangulated hernia E Adhesions

Adenocarcinoma Large bowel obstructions are most commonly caused by an adenocarcinoma (65%). This is followed in decreasing incidence by diverticular scarring and volvulus. Adhesions are the most common cause of small-bowel obstruction but are rare as a cause of large bowel obstruction. The presence of haustral markings on radiographic evaluation helps differentiate between small and large bowel involvement.

A 23-year-old female who has a history of supraventricular tachycardia is having an acute episode again. She has attempted a valsalva maneuver without success in breaking the arrhythmia. The ECG confirms SVT. What is the next step in therapy for this patient? A Atropine B Amlodipine C Adenosine D Amiodarone E Metoprolol

Adenosine C Intravenous adenosine is the treatment of choice in this clinical situation. If successful the adenosine will break the cycle of tachycardia, usually with a pause. The initial dose is 6mg, followed by two, 12 mg doses if unsuccessful. While this is the standard protocol as guided by ACLS, additional doses of adenosine can be given in a hospital setting, as the half-life of the drug is extremely short. Amiodarone and amlodipine would not have an effect on the supraventricular effect of the arrhythmia.

What is the treatment for wide complex stable supraventricular tachyhardia? What is management after we have the patient controlled?

Adenosine Procainamide Amiodarone Digoxin

A 16-year-old high school boy presents to the emergency department 4 hours after sustaining an abrasion to his knee after a fall while rollerblading on the school playground. His school immunization record reveals that his last diphtheria, tetanus, and pertussis (DTaP) booster was administered at age 4. In this situation, which of the following is the MOST appropriate plan? A administer tetanus toxoid B administer adult tetanus and diphtheria toxoid (Td) C administer diphtheria, tetanus toxoid, and acellular pertussis (Tdap) vaccine D administer tetanus immune globulin

Administer diptheria, tetanus toxoid, and acellular pertussis (Tdap) vaccine Generalized tetanus (lockjaw) is a neurologic disease caused by Clostridium tetani. Although any open wound is a potential source for contamination with C tetani, those with dirt, soil, feces, or saliva are at increased risk. Tetanus-prone wounds contain devitalized tissue, especially those caused by punctures, frostbite, crush injury, or burns. Recommendations for tetanus prophylaxis in a child with a laceration or abrasion depend upon the number of previous vaccinations, occurrence of last booster, type of wound (clean or tetanus-prone), and age of child. In this case, the patient is older than 7 years and had all of his previous immunizations; however, his most recent booster was greater than 10 years ago. Thus, he should receive an adult-type diphtheria and tetanus toxoid with acellular pertussis. In most cases, when tetanus toxoid is required for wound prophylaxis in a child older than 7 years, the Td instead of tetanus toxoid alone is recommended so that diphtheria immunity is maintained. If tetanus immunization is not up to date at the time of wound treatment, then the immunization series should be completed according to the primary immunization schedule. If a child is younger than 7 years, then the diphtheria, tetanus, acellular pertussis (DTaP) booster is indicated, unless there is a contraindication for pertussis, in which case the diphtheria and tetanus (DT) booster should be administered. Tetanus immune globulin (TIG) is recommended for treatment of tetanus. Under special circumstances, a patient infected with the human immunodeficiency virus (HIV) with a tetanus-prone wound should also receive TIG in addition to the prophylactic vaccine.

What age group is most at risk to develop osteoid osteoma? A Adolescents B Elderly C Middle-aged D Neonates E Toddlers

Adolescents Osteoid osteoma is a benign bone forming tumor that usually develops during a patient's second decade of life. This type of tumor is much more common in boys than girls and typically affects the lower extremities (femur and tibia primarily) and spine more than other areas of the body. Patients typically present with gradually progressive bone pain that is worse at night and does not correlate with activity level. The tumor produces high levels of prostaglandins, so symptoms usually improve in 20-25 minutes if the patient takes a medication like ibuprofen, ASA or other NSAIDS that are prostaglandin inhibitors. A lack of improvement in symptoms with these medications should lead health care providers to consider a different diagnosis. The pain of this condition may cause those afflicted in a leg to limp and have swelling, muscle atrophy or contractures and exquisite point tenderness. The condition usually resolves on its own over time, but symptomatic patients may require surgical resection or radioablation of the tumor.

Altered mental status, weakness, dehydration, hypotension, N/V, weight loss, abdominal pain, hyperpigmentation, metabolic acidosis, hyperkalemia, hyponatremia, hypoglycemia. Dx and tx.

Adrenal Insufficiency/Crisis -5% dextrose in NS (immediately) -Hydrocortisone -Vasopressors (if fluids do not work)

Recent travel followed by localized inflammation at site of a fly bite that turns to a painless chancre with intermittent fevers, rash, behavioral and neurologic changes. Dx and tx.

African Trypanosomiasis (Sleeping Sickness) -Suramin -Consult infectious disease

In a person with hypo or hypercalcemia, what other lab must be ordered and why?

Albumin because 50% of calcium is protein bound

What are common causes of pancreatitis? Common symptoms?

Alcohol abuse, gallstones, hyperlipidemia, hypercalcemia Severe constant epigastric pain radiating to the back. Better when leaning forward. N/V, Upper abdominal tenderness

Alcohol intake 24-72 hours ago followed by N/V, abdominal pain, dehydration, kussmaul's respiration, tachycardia, anion gap metabolic acidosis, serum ketones. Dx and tx.

Alcoholic ketoacidosis -Thiamine before dextrose (to prevent Wernicke's) -D5NS

Most common cause of hypomagnesemia?

Alcoholism

Which type of chemical burn is worse - acid or alkali?

Alkali burn

Chemical spilled on arm. Liquefaction necrosis. Dx and tx.

Alkali burn -Copious irrigation with water (UNLESS sodium, lithium, calcium, or magnesium metals -> Mineral oil) -Tetanus

Which of these structures can sense pain in the brain: extracranial structures proximal venous sinuses and brances (just beyond circle of Willis) dura overlying the base of brain

All of them -- most intracranial structures can not sense pain though (brain parenchyma, arachnoid, pia, upper portions of dura)

Recent travel with alternating constipation and diarrhea, colitis, abdominal pain, fever, weight loss. Dx and tx.

Amebiasis (entamoeba histolytica) -Metronidazole

Urticaria, angioedema, bronchospasms, hypotension, dilated pupils, loss of consciousness. Dx and tx.

Anaphylactic shock -Intubate ASAP -EPI -Diphenhydramine -Histamine blockers -Glucocorticoids -Beta agonists

Koilonychia (spoon nails), pallor, cheilosis (fissures at the corner of the mouth) are characteristic of...

Anemia

Hypertension Drug of Choice for: angina diabetes hyperlipidemia CHF Previous MI Chronic Renal Failure Asthma, COPD

Angina - BB, CCB Diabetes - ACEi & CCB, avoid diuretics Hyperlipidemia - ACEi & CCB, avoid diuretics/BB CHF - diuretics & ACEi, avoid CCB/BB Previous MI - BB/ACEi Chronic renal failure - diuretics, CCB Asthma - diuretics & CCB, avoid BB

_____remains the gold standard for diagnosis of intestinal ischemia and may provide a route for infusion of vasodilatory drugs such as papaverine to help restore blood flow to the threatened segment of bowel.

Angiography

A 16-year-old girl is brought to the emergency department by ambulance after reportedly ingesting "a bottle of aspirin." Vital signs are temperature 37.8°C oral; pulse 94/min; respirations 30/min; blood pressure 100/68 mm Hg. What would you expect the blood gases to show that would confirm she had swallowed the aspirin? A anion gap metabolic acidosis with respiratory acidosis B nonanion gap metabolic acidosis with respiratory alkalosis C anion gap metabolic acidosis with respiratory alkalosis D nonanion gap metabolic acidosis with respiratory acidosis

Anion gap metabolic acidosis with respiratory alkalosis An acute salicylate overdose (greater than 150 mg/kg) will produce symptoms of salicylate intoxication. Chronic salicylate intoxication occurs with ingestion of greater than 100 mg/kg/day for at least 2 days. Salicylates affect most organ systems, leading to various metabolic abnormalities. Because salicylates are a gastric irritant, symptoms of vomiting and diarrhea occur soon after the overdose, which may contribute to the development of dehydration. Salicylates stimulate the respiratory center leading to hyperventilation and hyperpnea resulting in respiratory alkalosis and compensatory alkaluria. A characteristic feature of salicylate intoxication is the coexistence of a respiratory alkalosis with a widened anion gap metabolic acidosis.

A 20-year-old male presents to the emergency department complaining of pain to the right shoulder region while playing basketball. He states that his arm was pulled back and rotated while he was moving forward, and then felt a popping sensation in the shoulder. Since then he has not been able to move the shoulder at all due to pain and immobility. It is suspected that he has a dislocation. Given this scenario, what would be the most likely type? What type of shoulder dislocation did he most likely experience? A Anterior B Inferior C Multidirectional D Posterior E Superior

Anterior All of the various types of dislocations mentioned above are possible, but anterior dislocations are by far the most common (>95%) and they are the most common of all joint dislocations. Most occur as a result of a fall or other traumatic event and they may become recurrent. The shoulder is most susceptible to an anterior dislocation when it is abducted and externally rotated. The shoulder joint is considered a very mobile joint, but this also renders it very susceptible to injury.

What is the most common ankle sprain?

Anterior Talofibular ligament

A 52-year-old male has a 200-pound file cabinet fall on his right leg. He comes to the emergency department complaining of pain and swelling to the right leg. He is also complaining of parasthesias to the leg also. Based on these findings on history, what part of the leg would be the most likely site of compartment syndrome? A Anterior compartment of the leg B Deep posterior compartment of the leg C Dorsal compartment of the forearm D Lateral compartment of the leg E Superficial posterior compartment of the leg

Anterior compartment of the leg Anterior compartment syndrome is most commonly found in the anterior compartment of the leg, with the volar compartment of the forearm also a common location. The mechanism is generally an acute crushing trauma to the affected area that causes an increase in pressure within the compartment that inhibits venous outflow and a decrease in arterial blood flow. This adversely affects tissue perfusion and ischemia of the involved tissues can occur. The symptoms can also occur with chronic exertion or when there is a dramatic increase in the amount of exercise being performed. Anterior compartment syndrome of the leg is likely most common due to its vulnerable location and susceptibility to injury in athletics and motor vehicle accidents. The rate of occurrence of acute anterior compartment syndrome is also likely due to the fact that the anterior compartment lies adjacent to the tibia and the tibia is the most frequently fractured long bone. Compartment syndrome could occur in any compartment of the upper or lower extremities if the necessary circumstances were in place (either acute trauma to the area or excessive use of the muscles that are associated with each of the compartments)

Which incomplete spinal injury has the worst prognosis?

Anterior cord syndrome

____occurs when the anterior aspect of the spinal cord is injured. Paralysis and loss of pain/temp sensation distal to the injury. Position, touch, and vibration sense is usually preserved. Prognosis poor.

Anterior cord syndrome

Following trauma to the spine, there is complete paralysis in the legs with loss of temperature and pain sensation, but preserved proprioception and vibratory sensation. Dx.

Anterior cord syndrome (incomplete spinal injury)

Which type of shoulder dislocation is most common?

Anterior dislocation

A 23-year-old college basketball player twists her ankle while practicing. She explains the injury that is consistent with an inversion mechanism. Based on this history, what ligament would you expect to be the most likely injured in the ankle of this patient? A Anterior talofibular B Anterior tibiofibular C Calcaneofibular D Deltoid E Posterior talofibular ligament

Anterior talofibular Greater than 25,000 ankle sprains happen in the USA every day and the vast majority of those are inversion ankle sprains. The anterior talofibular ligament is the first, and often only, ligament damaged in inversion ankle sprains. As the force of the inversion increases, other lateral ankle ligaments can be involved. When the anterior tibiofibular ligament is involved, this is referred to as a high ankle sprain and such injuries generally have a prolonged recovery time. Calcaneofibular ligaments are generally the second most frequently injured of the lateral ankle ligaments and when injury occurs it is typically in combination with the anterior talofibular ligament. The deltoid ligament is a very strong ligament on the medial aspect of the ankle. Eversion stresses the deltoid ligament, but strong eversion forces are rare and when they do occur, an avulsion fracture of the medial malleolus is more likely than a significant ligament tear. The posterior talofibular ligament is one of the lateral ankle ligaments and can be injured in an inversion injury, but the rate of injury to this ligament lags far behind the anterior talofibular or calcaneofibular ligaments.

What is the Rule of nines in burn injuries?

Anterior torso - 18% Posterior torso - 18% Arms - 9% each Legs - 18% each Head - 9% Genitals 1%

ST Elevations in V1, V2, V3, V4, V5

Anterioseptal MI, left anterior descending artery

MC valvular defect that → Syncope?

Aortic Stenosis AS Triad: "ASH" (angina, syncope, HF)

_____is a diastolic murmur heard along left sternal border. Austin-Flint murmur. What kind of pulse?

Aortic regurgitation; "water hammer" pulses

Two patients are triaged into the ER. with syncope. One is a 67 y/o who was playing with her grandchildren when she felt short of breath and passed out. The second patient is a 34 y/o patient who was doing his taxes when he passed out unexpectantly. What is the likely cause of each syncopal episode?

Aortic stenosis in the elderly woman- first thought with elderly dysrhythmia in the young adult- no prodrome

What structural causes may cause cardiac syncope? Which is *most common* among the elderly population?

Aortic stenosis, hypertrophic cardiomyopathy, PE, and MI Aortic stenosis

____is a decrescendo-crescendo rough, systolic murmur. Heard best at base of heart and radiates to neck. What drug is contraindicated?

Aortic stenosis; ACEi

_________is considered the gold standad test for aortic dissection but is also the most invasive of all the radiographic studies. What is more normally done in the ED?

Aortography; CT with contrast

____is a disease in which the bone marrow and stem cells that reside there are damaged. This causes a deficiency of RBC, WBC, and platelets. CBC shows pancytopenia. What hemoglobin requires small volumes (3-5ml/kg) over 3-4 hours to be infused? What can happen if given too rapidly? What is their best chance for survival?

Aplastic anemia; </-6g/dL; heart failure; bone marrow transplant

Patient presents with decreased pulses in their legs, skin pale and cool to touch, and shiny...diagnosis? How can we remember these symptoms?

Arterial insufficiency Pain, Pallor, Parasthesia, paralysis pulselessness, and poikilathermia

___ulcers usually have punched out appearance on lateral foot. No hair. ____ulcers usually have edema, contact dermatitis, and irregularly shaped sores.

Arterial; Venous

How long do we use treatment for hep B? How long do we wait for a reaction?

As long as it works 4 months- if no improvement, DC

Eating food from a street vendor, dry cough, fever, weakness, malnutrition. Dx and tx.

Ascariasis roundworm -Mebendazole

Common complication of late hypothermia?

Aspiration

A 36-year-old man presents to the emergency department with a tight bandage around his chest to help reduce pain from a chest wall injury on his right side that occurred during mixed martial arts sparing. Physical exam reveals dullness to percussion, dry crackles and diminished breath sounds over the right lower lobe. Chest x-ray shows elevation of the right hemi-diaphragm. What is the most likely diagnosis? A Atelectasis B Bronchiectasis C Pleural Effusion D Pneumothorax E Pulmonary edema

Atelectasis The patient's injury places him at risk of atelectasis, pneumothorax, or other traumatic injuries. The physical exam and chest x-ray findings are classic for atelectasis (A). Pleural effusion (C) would present with fluid in the costophrenic angle on chest x-ray. Pneumothroax (D) would typically present with findings in the upper lung fields including hyperresonance to percussion. Pulmonary edema (E) would present with increased vascular markings and evidence of fluid within the alveolar space on chest x-ray.

A positive Coombs test indicates...

Autoimmune hemolytic anemia

What are you concerned about in a Lunate and Perilunate dislocation?

Avascular necrosis due to neurovascular compromise (usually median nerve)

A 22-year-old man is brought to the emergency department by paramedics after having sustained a single stab wound along the left sternal border at the fourth intercostal space. Upon arrival to the emergency department, he was hypotensive and tachycardic. The neck veins were distended and heart sounds were muffled. Which of the following interventions is the most appropriate first-line management of this patient? A Left tube thoracostomy B Pericardiocentesis C Fluid resuscitation D Immediate intubation

B Cardiac tamponade is classically described by the triad of jugular venous distension (JVD), arterial hypotension, and muffled heart sounds. In the emergency department, suspicion of this clinically entity is usually confirmed by ultrasonography and is acutely treated by pericardiocentesis, which will be diagnostic, therapeutic, and buy time until a definitive procedure can be done. A left tube thoracostomy may be indicated in this patient but would not relieve symptoms. Fluid resuscitation though applied to all trauma patients would help stabilize the patient until more therapeutic interventions could be completed. Immediate intubation, even if indicated, would require a prophylactic tube thoracostomy to prevent the development of tension pneumothorax in the event of an unrecognized lung injury. Emergency thoracotomy will relieve the signs and symptoms associated with cardiac tamponade and allow for repair of any underlying cardiac injuries.

What treatment do we give HF pt? What is the initial tx?

BADD- BB, ACE, Diuretics, Digoxin Diuretic and ACE

What medications may help treat a MI in addition to MONA?

BASH- Beta Blockers, ACE, Statin, Heparin

A patient with MI who also has HF should be treated with what?

BB

What medicine type, if any, do we give for hypertrophic cardiomyopathy?

BB

Which medication is the treatment of choice for symptomatic patients with hypertrophic cardiomyopathy? A Calcium channel blockers B Nitrates C Thiazide diuretics D Alpha antagonists E Beta-blockers

BB E The use of beta-blockers in symptomatic hypertrophic cardiomyopathy is useful for gaining rate control. This will allow for the optimal amount of filling in order to maintain enough of an ejection fraction.

What two meds should be given to all ACS patients that do not have contraindications?

BB - unless brady or severe COPD - then do NDCCB (verapamil/diltiazem) ACEi - if cough, use ARB

Thrombolytic Therapy -- used for MI, stroke, and PE -- what are the absolute contraindications? BHTARC

BHTARC 1. active bleeding 2. hemorrhagic stroke, CVA, TIA in last year 3. intracranial tumor 4. suspected aortic dissection 5. diabetic retinopathy 6. altered level of consciousness

What is the initial test for heart failure?

BNP

_____is released from cardiac ventricles in response to increased wall tension.

BNP - B-type natriuretic peptide

Blood Volume: -Best way to asses?

BP & HR

What is the most common fracture-dislocation of the wrist joint?

Barton's fracture

Intra-articular fracture of distal radius with dorsal displacement of distal fragment combined with carpus subluxation. Dx and tx.

Barton's fracture (wrist slightly above forearm; piece of radius coming off) -Closed reduction and sugar tong splint

Patient with pink pearly papule, surface tangielectasia has what? Where is this lesion most likely?

Basal cell Nose

What is the most common skin cancer? Describe it.

Basal cell Pinky pearly papule, surface tangliecttasia, slow growing. MC on the nose

How can some people survive a lightening strike?

Because it flashes over the skin rather than through the body

More common fractures: ____is fracture/dilocation of thumb at the carpometacarpal joint. ____is Y-shaped three part fracture of thumb at carpometacarpal joint. ____is injury to the ulnar collateral ligament of thumb MCP joint w or wo fracture. ____is an oblique fracture through the base of the radial styloid. ____is an intra-articular fracture with a displaced radial articular fragment.

Bennett, Rolando, Gamekeeper's, Chauffeaur, Barton's

A 65-year-old recent alcoholic comes to the emergency department with recent onset of dyspnea, with exertion, 3 pillow orthopnea, lower extremity edema, and palpitations, in which he describes his heart as racing. Which of the following is most likely to be the cause of his high-output congestive heart failure? A Mitral regurgitation B Aortic stenosis C Uncontrolled hypertension D Ruptured chordae tendinae E Beriberi

Beriberi Choice E, beriberi, also known as thiamine deficiency, is common among alcoholics, and the only high-output cause of congestive heart failure among the choices offered. Other causes include severe anemia, thyrotoxicosis, and arteriovenouis shunting (for example, in hemodialysis patients). Choice A, mitral regurgitation, is a cause of excessive preload, leading to heart failure. Choice D, ruptured chordate tendinae associated with mitral regurgitation, would also be a cause of excessive preload, leading to heart failure. Choices B and C, aortic stenosis and uncontrolled hypertension, are causes in which too much afterload leads to heart failure

___should NEVER be used in the treatment cocaine associated chest pain.

Beta Blockers

Immediate pinprick sensation from spider bite that quickly spreads throughout extremity. Target shaped lesion at site of bite. Muscle cramps, tachycardia, N/V. Dx and tx.

Black Widow bite -Latrodectus antivenom -Analgesics for pain -Benzos for cramping

The black widow and brown recluse spider produce severe reactions. Treatment is ice to prevent venom spread, local wound care, and abx for severe necrosis. Which spider has a antivenom that can be given for acute symptoms.

Black widow antivenom

What is the most common cause of anemia?

Blood loss

Blood loss, blood volume, pulse, BP, respiratory rate, urine output, and mental status - Class 3 hypovolemic shock?

Blood loss = 1500-2000 ml Blood volume lost: 30-40% Pulse: >120 BP: decreased Respiratory rate: 30-40 Urine output: 5-15ml Mental status: anxious and confused

Blood loss, blood volume, pulse, BP, respiratory rate, urine output, and mental status - Class 1 hypovolemic shock?

Blood loss = 750 ml Blood volume lost: <15% Pulse: normal (<100) BP: normal Respiratory rate: normal (14-20) Urine output: >30 ml Mental status: slightly anxious

Blood loss, blood volume, pulse, BP, respiratory rate, urine output, and mental status - Class 2 hypovolemic shock?

Blood loss = 750-1500 ml Blood volume lost: 15-30% Pulse: >100 BP: normal Respiratory rate: 20-30 Urine output: 20-30 ml Mental status: mild anxious

Blood loss, blood volume, pulse, BP, respiratory rate, urine output, and mental status - Class 4 hypovolemic shock?

Blood loss: >2000 ml Blood volume lost: >40% Pulse: >140 BP: decreased Respiratory rate: >35 Urine output: none Mental status: confused and lethargy

Partial flexion at PIP and extension at DIP. Dx and tx.

Boutonniere deformity Splint in extension

Common Fractures: ____is fx of neck of fourth or fifth metacarpal, striking w clenched fist. ____is fx of distal radius with dorsal displacement, FOOSh ____is fx of distal radius with volar displacement, fall on back of hand. ____is fx/dislocation of atlas and axis, due to extreme hyperextension during abrupt deceleration.

Boxer's fracture, Colles fracture, Smith fracture, Hangman's fracture

A patient is brought to the Emergency Department by ambulance. He is a 27-year-old male who is well known to the paramedic team as a heroin addict. He is arousable and does not remain alert when aroused. Which of the following physical signs would help to confirm the diagnosis of opioid intoxication? A Bradycardia B Diaphoresis C Mydriasis D Rhinorrhea E Tachypnea

Bradycardia Bradycardia (A), lowered respiratory rate, miosis and somnolence are the main effects of opiates. As with most medications, withdrawal effects are the opposite of the effects of overdose. Tachycardia, tachypnea, rhinorrhea and diaphoresis (B, D, & E) can all occur in opiate withdrawal. Mydriasis (C) is common with other substances of abuse, such as cocaine and LSD.

_______is the abnormal dilation of large conducting airways - due to congenital abnormalities (cystic fibrosis) or an acquired process (alplha-1-antitrypsin deficiency).

Brochiectasis

Foreign body aspiration: S/S ____aspiration presents with cough, decreased air entry, dyspnea, and wheezing ____aspiration presents with cough, cyanosis, dyspnea, and stridor

Bronchial; Laryngotracheal

Localized firm erythematous lesion from a painless spider bite that then becomes necrotic over a few days forming an eschar. Dx and tx.

Brown Recluse bite -Supportive tx (pain meds, tetanus prophylaxis) -Most wounds heal without intervention -Admit if systemic reaction -Consult surgery if lesion > 2 cm

____occurs when a lateral half of the spinal cord is injured at a specific level. Ipsilateral motor paralysis and contralateral sensory loss. Prognosis good.

Brown-Sequard syndrome

Following trauma to the spine, there is spastic paralysis on the right side of the body, loss of proprioception and vibration sense on the right side, loss of pain and temperature sensation on left side. Dx.

Brown-Sequard syndrome (incomplete spinal injury)

____is autoimmune blistering disease that primarily affects the elderly, IgG, biopsy shows subepidermal bulla with infiltration of eosinophils. Treatment?

Bullous pemphigoid; tx - steroids and possibly minocycline

A _____may develop after acute MI, PE, aortic stenosis and is due to a conduction delay in the right or left bundles.

Bundle branch block

A 48-year-old man is brought to the emergency department by his sister after suffering from loss of consciousness, followed by muscle rigidity and rhythmic contractions, and then a return to a normal state. When asked about medication use, the patient states he is currently being treated with a drug for depression but cannot remember the name. He claims that he has never had a seizure or seizure-like activity prior to this event. Approximately 6 hours after the first episode, the patient suffers a second one while still in the ED. Which of the following medications is the patient most likely taking? A bupropion B duloxetine C fluoxetine D nortriptyline E phenelzine

Bupropion Bupropion has been shown in some patients to cause seizures in a dose-dependent fashion, particularly in those with a history of head trauma or electrolyte abnormalities. Tricyclic antidepressants (eg, nortriptyline), selective serotonin reuptake inhibitors (eg, fluoxetine), serotonin-norepinephrine reuptake inhibitors (eg, duloxetine), and monoamine oxidase inhibitors (eg, phenelzine) have not been associated with seizures.

A 27-year-old female presents to the emergency department after a motor vehicle accident. Imaging of the left lower extremity shows the following fracture pattern: How would this fracture be described? A No displacement B Complete dorsal displacement C Fifty percent dorsal displacement D Displacement with shortening

C This Fracture is displaced, pertaining to any deviation from anatomical position or alignment to the extent to which the fracture fragments are nonconcentric or offset from each other. This fracture is only 50 percent displaced without angulation or shortening. The magnitude of displacement is expressed in either terms of measurement (i.e. incomplete) or percentage (i.e. 50%) ) of the width of the bone. The direction of displacement is based on the position of the distal fragment relative to the proximal fragment. Separation is the distance two fragments have been pulled apart. Shortening (D) is the amount the bone's length has been reduced, which is not seen in this fracture. Angulation is the degree of "bending" that makes the fragments unparalleled. This would not be described as "no displacement" (A) or "complete displacement" (B).

Out of all cervical vertebrae, which two are responsible for the greatest amount of rotation? A C1 & C2 B C2 & C3 C C3 & C4 D C4 & C5 E C5 & C6

C1 & C2 A Approximately 50% of cervical rotation takes place between the C1 (atlas) and C2 (axis) vertebrae. These first two cervical vertebrae have a different shape from the other cervical vertebrae that allow for this greater range of motion. The remaining 50 % of cervical rotation is split fairly evenly between the remaining vertebrae. Approximately 50 % of flexion and extension occurs between the occiput at the base of the skull and C1 with the remaining 50% distributed fairly evenly between the remaining vertebrae with a slightly higher percentage occurring at the C5 & C6 level.

What cervical spine vertebrae innervate the diaphragm?

C3 through C5

Cervical and Lumbar Radiculopathies C5 - motor weakness? decreased reflex? decreased sensation?

C5 motor - deltoids/biceps reflex - biceps sensation - deltoids

Cervical and Lumbar Radiculopathies C6 - motor weakness? decreased reflex? decreased sensation?

C6 motor - biceps, wrist extensors reflex - biceps sensation - dorsolateral aspect thumb and index finger

Cervical and Lumbar Radiculopathies C7 - motor weakness? decreased reflex? decreased sensation?

C7 motor - triceps, finger extensors reflex - triceps sensation - index, long fingers, dorsum of hand

Multifocal atrial tachycardia - noted in patients with COPD or severe systemic illness - EKG shows multiple shaped P waves and differing PR intervals. ____are agents of choice?

CCB

Panic disorder is frequently encountered in the ED and the s/s mimic those of other illnesses. What tests should be done for the diagnosis of exclusion?

CK, troponins, D-dimer, EKG, radiographic studies

Most common cause of serious opportunistic viral disease in HIV patients?

CMV

What is the leading cause of blindness in HIV patients?

CMV retinitis

What are three causes of MAT?

COPD, theophylline toxicity, and B-adrenergic treatments

____presents as acute, painless, monocular vision loss in addition to risk factors for the disease ie. HTN, a fib, atherosclerosis, collagen vascular disease etc.

CRAO - central retinal artery occlusion

A 16-year-old boy sustained a head injury during wrestling practice. During a practice match, the boy's head struck the concrete floor and he then received a secondary blow to the head by nearby wrestler. He briefly lost consciousness and then was dazed, confused, and slow to respond to questions for a few minutes. His vision became briefly blurry and double. His balance was initially unstable but improved with time; however, he developed lethargy and a headache. He did not have any nausea or vomiting. His mother was instructed to have him checked for a head injury. On exam about an hour later, he appears tired but is alert and oriented and able to recount the events leading to his injury, though he is a somewhat unsure about what happened right after. His vitals are stable, and visual acuity is 20/40 in both eyes; head and neurologic exam are normal, including equal and reactive pupils and cranial nerves. His very anxious mother says he suffered a concussion 2 seasons ago while playing football and had to sit out practice for 2 weeks. Question What management options would be best for this patient? Answer Choices 1 Observation only 2 Cranial CT scan 3 MRI 4 Skull radiographs 5 Ultrasonography

CT Cranial CT scanning, after a thorough history, physical, and neurologic examination, may be used in addition to observation in the management of children with minor closed head injury with loss of consciousness. Loss of consciousness is uncommon but is associated with an increased risk for intracranial injury. Some studies have suggested that a loss of consciousness, amnesia at the time of evaluation, or headache or vomiting has a prevalence of intracranial injury detectable on CT ranging from 0% to 7%. Furthermore, neurosurgical intervention may be required in 2% to 5% of those. Compared to MRI scans, CT scans are more sensitive for hyperacute and acute intracranial hemorrhage and are more quickly, easily, and cheaply performed. In the absence of available CT scanning, MRI scanning may be an acceptable option. Consensus is that observation alone (after a thorough history and physical plus normal neurologic exam are performed in the clinic, office, ED, or home under care of a competent observer) can be used as the primary management strategy in patients who present with no loss of consciousness, amnesia, vomiting, headache, or mental status changes. Parents or guardians would require careful instructions about when to seek medical attention for a worsening condition. A careful assessment of the caregiver's compliance with instructions must be made and may differ in individual cases; other factors to weigh include distance and time it would take to reach appropriate medical care if the patient's condition worsened. Skull radiographs have a very limited role in head injury evaluation of the child with loss of consciousness. A substantial rate of false-positive results where a fracture is detected without intracranial injury, and the low prevalence of intracranial injury among this specific subset of patients, leads to a low predictive value of skull radiographs. Furthermore, intracranial injury can also occur in the absence of a skull fracture. If imaging is desired, CT scanning is the modality of choice based on increased sensitivity and specificity. The use of ultrasound in traumatic brain injury is being evaluated to measure the optic nerve distensible sheath diameter. This method can predict raised intracranial pressure.

What imaging modality is a very accurate means to differentiate ischemic from hemorrhagic stroke? What is the imaging gold standard for stroke? In general, ischemic strokes are not visible on noncontrast CT of the head until at least ____ hours after brain infarction.

CT - noncontrast; CT angiography; 6 hours

What are the imaging modalities of choice for the detection of intraabdominal injury after trauma?

CT abdomen or ultrasound

What is the test of choice for aortic dissection?

CT aortagram or transesophageal echocardiogram

Patient presents with tachycardia, tachypnea, and recently had hip surgery. Hypoxia is noted. What is the BEST test for diagnosis?

CT pulomnary angiography

What is the definition of hypocalcemia?

Ca < 8.5

What is the definition of hypercalcemia?

Ca > 10.5

Headache, N/V, dizziness with anion gap metabolic acidosis in a person recently exposed to gas or smoke inhalation. Dx and tx.

Carbon Monoxide poisoning -Highest concentration of supplemental oxygen available until symptoms go away -Hyperbaric oxygen (possibly)

_____presents with distended neck vein, indistinct heart sounds, narrow pulse pressure, and pulsus paradoxus. Tx: pericardiocentesis and treat underlying cause.

Cardiac tamponade

Hypotension, elevated JVP, distant/muffled heart sounds, pulsus paradoxus, electrical alternans, low voltage QRS complexes. Dx and tx.

Cardiac/Pericardial Tamponade -Emergent cardiology consult -IV fluid bolus -Pericardiocentesis -Admit to ICU

What is the most common cause of death after lightening strike?

Cardiac/respiratory arrest

Decreased exercise tolerance, dyspnea, pulsus paradoxus, hypotension, tachycardia, altered mental status, rales, JVD, elevated BNP, elevated lactate. Dx and tx.

Cardiogenic Shock -Emergent cardiology consult -Oxygen -Nitroglycerine or Morphine (for chest pain) -NE (for hypotension) -Cath lab = definitive tx

What is the leading cause of death in MI?

Cardiogenic shock

Hypotension, cool and clammy skin, oliguria, tachypnea, wheezing, S3, S4, JVD without pulmonary edema. Dx and tx.

Cardiogenic shock -Morphine -Oxygen -Nitro -Aspirin -Dopamine -Dobutamine

How do we treat unstable supraventricular tachyhardia?

Cardioversion

A 64 y/o has returned to the ER for the 3rd time this month with reported syncope. Previous (and current) cardiac work-up has been completely unremarkable. What cause of syncope should we begin to consider?

Carotid sinus hypersensitivity

What is Trousseau sign?

Carpal spasm when blood pressure cuff is left inflated above systolic BP Indicates hypocalcemia

What is the definitive tx for Cardiogenic Shock?

Cath lab (percutaneous coronary intervention PCI)

_____is due to reduction in volume of lumbar spinal canal, causing compression and paralysis - presents w leg weakness, urinary and anal sphincter control.

Cauda Equina syndrome

Cause and tx for heat syncope?

Cause: volume depletion, peripheral vasodilation, decreased vasomotor tone (particularly in elderly) -Rest -Rehydration

Tx for Gonorrhea and Chlamydia?

Ceftriaxone IM single dose + Azithromycin 1 gram po single dose

____is infection of the deep dermis and subcutaneous tissue. Empiric antibiotic therapy should be directed against staph and strep organisms. Dicloxacillin, augmentin, first generation cephalosporin

Cellulitis

Localized tenderness, erythema, and induration. Fever and chills. Dx and tx.

Cellulitis -Cephalexin po (if no MRSA) -Clindamycin (if MRSA) -Follow-up in 2-3 days

What are the two forms of Diabetes insipidus?

Central (pituitary, neurogenic, neurohypophyseal)- associated with decreased ADH Nephrogenic D- Doesn't react to ADH

What would happen if you corrected the sodium too fast in a person who is hyponatremic?

Central Pontine Myelinolysis

____syndrome typically occurs with cervical hyperextension when the ligamentum flavum buckles into the spinal canal and pinches the cord. Usually manifests as weakness - upper extremities more than lower. Prognosis good.

Central cord syndrome

Following trauma to the spine, there is quadriparesis (more in upper extremities) and loss pain and temperature sensation (more in upper extremities). Dx.

Central cord syndrome (incomplete spinal injury)

What type of DI reacts to a water deprivation test?

Central...nephrogenic does not

Scuba diver ascends and has seizure, blindness, hemiplegia, loss of consciousness. Dx and tx.

Cerebral Arterial Gas Embolism (CAGE) -100% oxygen -IV fluids -Place patient in supine position -Recompression therapy (hyperbaric oxygen) -Lidocaine

What would happen if you corrected the sodium too fast in a person who is hypernatremic?

Cerebral edema

Unilateral periorbital edema (Romana sign), painful cutaneous edema (Chagoma), lymphadenopathy, hepatosplenomegaly. Dx and tx.

Chagas disease (American Trypanosomiasis) -Nifurtimox -Consult infectious disease

Trauma: Ecchymosis over lower abdomen from lap belt is associated with a lumbar spine fracture ie. ____fracture. Ecchymosis over flanks or _____sign or umbilicis ie. ____sign may represent retroperitoneal hemorrhage.

Chance fracture, Grey Turner's sign, Cullen sign

Tender papule that turns into a painful purulent ulcer on the external genitalia with unilateral inguinal adenopathy. Dx and tx.

Chancroid -Azithromycin 1 gram po single dose

What are the classic symptoms of arotic stenosis?

Chest pain, dyspnea on exertion, and syncope

Outdoor exposure followed by intense pruritus near waste bands with papules that enlarge to nodules over a couple days. Dx and tx.

Chiggers -Oral or topical antihistamines -Topical permethrin

What types of electrical injury do children usually have? adults?

Children = low voltage (< 1000 V) from electrical outlets Adults = high voltage (> 1000 V) while at work

Clostridium and Bacteroides fragilis are the typical pathogens for _________. Bacteroides fragilis and E Coli are the typical pathogens for ______. What are the imaging modalities of choice for cholecystitis and appendicitis?

Cholecystitis; appendicitis; Chole - ultrasound, then HIDA; Appendicitis - CT scan

Recently ate shellfish, profuse watery diarrhea, vomiting, dehydration. Dx and tx.

Cholera -Rehydration -Tetracycline

Patients diagnosed with an auricular hematoma are at increased risk of developing which condition? A Cartilage necrosis B Cholesteatoma C Coagulopathy D Exostosis E Otomycosis

Cholesteatoma Auricular hematomas occupy the subperichondral space, leading to decreased or absent diffusion from the perichondrium to the cartilage and resulting in increased risk of necrosis (A). Coagulopathy (C) may predispose a patient to experiencing a hematoma. Cholesteatoma (B) may result from TM trauma, but not blunt trauma to the outer ear.

_____refers to the condition of excess mucus production and productive cough occurring for at least 3 months a year for 2 consecutive years. "blue bloater", course rhonchi

Chronic Bronchitis

What medication do we not give with diarrhea?

Cipro

You are performing a mental status exam on a 19-year-old male patient who was brought to the Emergency Department because of bizarre behavior. As you are speaking with him he keeps repeating words that rhyme with words that either you or he say, but make no sense and are unrelated to your questions. How will you document this behavior in his chart? A Circumstantiality B Clanging C Flight of ideas D Perseveration E Tangentiality

Clanging Word association based on rhyme is called clang association (B) and may be seen in psychotic disorders. Circumstantiality (A) is a disturbance in fluency where the speaker meanders on many side topics before returning to the topic at hand. Flight of ideas (C) is a rapid transition from thought to thought, leading to the speaker losing track of the original idea. Perseveration (D) is a fixed focus returning again and again to the same thought. Tangentiality (E) refers to a disturbance in continuity where the speaker shifts from one thought to another that may be only vaguely related.

Functional Classification of Heart Failure: ___-No cardiac symptoms with ordinary activity. ___-Cardiac symptoms w MARKED activity but asymptomatic at rest ___-Cardiac symptoms w MILD activity but asymptomatic at rest ___-Cardiac symptoms at rest.

Class I, Class II, Class III, Class IV

What medication must be gradually d/ced because abrupt stop could lead to rebound HTN?

Clonidine

A 68-year-old woman with a history of hypertension and diabetes mellitus type 2 comes to the emergency department with her son, who noticed that while decorating for Christmas she seemed more dyspneic than normal, and had to sit down frequently. In addition, he noticed that she was pale and diaphoretic, and insisted on driving her to the emergency department. On questioning, she denies chest pain, but admits to being more fatigued than usual, with frequent jaw discomfort during activity. Activities such as vacuuming her house cause dyspnea, and she now has to stop several times while carrying laundry up from the basement. On physical examination, the patient's blood pressure is 90/50, pulse 99 bpm, respirations 22, and she is afebrile. Auscultation of the chest demonstrates a new systolic murmur. An EKG demonstrates normal sinus rhythm with nonspecific ST and T wave changes. Serial troponin elevations above the 99 th percentile of normal are noted. Which of the following would be the most appropriate next step in the management of this patient? A Clopidogrel, heparin, and aspirin, followed by cardiac catheterization B Nuclear stress test C Treadmill stress test D Thiazide diuretics and loop diuretics

Clopidogrel, heparin, and aspirin, followed by cardiac catheterization In patients with non-ST-segment myocardial infarction, such as this patient with ischemic symptoms and serial troponin elevation above the 99 th percentile of normal, clopidogrel, aspirin, and heparin prior to cardiac catheterization are recommended, with the intention of percutaneous coronary intervention. In addition, morphine, oxygen, nitrates, beta blockade, ACE inhibitors, statin therapy, and glycoprotein IIb/IIa inhibitors should be considered, depending on the patient's blood pressure, heart rate, and hemodynamic stability. Choice D would be useful in the treatment of patients with hypertension and lower extremity edema. Choices B, C, and E, are all forms of stress testing, which should be performed in patients with symptoms of angina pectoris, but not for patients with acute myocardial infarction

Distal radius fracture fragment angled dorsally causing a "dinner fork deformity." Dx and tx.

Colle's fracture (wrist/hand above forearm) -Closed reduction and sugar tong splint

Tick bite in western mountains of US, fever, chills, myalgia, photophobia, petechial rash. Dx and tx.

Colorado Tick Fever (coltivirus virus) -Supportive tx

What is volkmann's contracture?

Compartment syndrome of the forearm - usually due to a supracondylar fracture

What is a Wedge fracture? What is the MOI?

Compression fracture of anterior vertebral column only MOI: -Spinal flexion -Axial loading

What is a Burst fracture? What is the MOI?

Compression fracture or anterior and middle vertebral columns MOI: -Spinal flexion -Axial loading

A pt presents with red lesions and white plaques on the vulve with a hx of intense hx over months...what is our concern?

Concern is neoplasm or cancer as squamos cell hyperplasia of the vulvus is seemingly evident

Which type of GU injuries can be treated outpatient?

Contusions to the: -kidney -bladder -testicles -scrotum -penis All other types of injuries aside from contusions need surgery

____is enlargement or dysfunction of the right ventricle due to pulmonary hypertension.

Cor pulmonale - may see prominent P waves in leads II, III, and aVF (anterior leads)

What is the definition of hypothermia?

Core body temp < 35 C (95 F)

_____refers to a superficial disruption of the surface of the cornea. Tx: update ____vaccine!, topical anesthetics, cycloplegic drops, irrigation, topical aminoglycoside or fluoroquinolone. What should not be given to take home?

Corneal abrasion; tetanus; topical anesthetics (bc its repetitive use impairs healing)

A patient is traiged with "chest pain" the PE reveals to be reproducible with palpation. What is the less seriour, more likely diagnosis and what serious diagnosis can we not rule out?

Costochondritis is less serious...PE still possible

A patient with small greyish vesicles and "punched out" ulcers in the posterior pharynx are indicative of what organism?

Coxasackie

Cardiac Markers: _____appears 3-6 hours after MI and stays elevated for 2-4 days. Specific to heart muscle.

Creatine kinase Mb

Recent swimming, watery diarrhea, fever, cramping, N/V. Dx and tx.

Cryptococcosis parasite -Supportive tx if health -Nitazoxanide (if older > 1 and immunocompromised)

A 65-year-old patient with steroid-dependent chronic obstructive lung disease presents with a headache that has been increasing in severity over the past week, accompanied by nausea and vomiting. He denies fever but has had photophobia and a stiff neck. Which of the following is the most likely diagnosis?

Cryptococcus- fungal infection is common in immunocompromised as this patient is with steroids. Progressive onset and afebrile presentation separate this patients dx Bacterial meningitis is possible but is usually more acute in presentation and has fever

What is the causative agent of West Nile Virus?

Culex Mosquitoes

________triad for finding cerebral perfusion pressure is CPP=MAP-ICP. Brain ischemia results when pressure is less than 40mmHg.

Cushing triad

Most common type of anthrax?

Cutaneous

Pruritic macule on fingers that ulcerates and forms multiple bloody vesicles followed by a painless black eschar. Dx and tx.

Cutaneous Anthrax -Cipro

Tetralogy of Fallot has what associated symptom?

Cyanosis

Eating undercooked pork, seizures, headaches, mental status change, hydrocephalus. Dx and tx.

Cysticercosis tapeworm -Praziquantel

The rotator cuff is comprised of which four muscles? A Scalenes, infraspinatus, teres minor, subscapularis B Supraspinatus, infraspinatus, teres major, subscapularis C Supraspinatus, infraspinatus, teres minor, soleus D Supraspinatus, infraspinatus, teres minor, subscapularis E Supraspinatus, intercostals, teres minor, subscapularis

D Supraspinatus, infraspinatus, teres minor, subscapularis D Only option D lists the correct muscles of the rotator cuff located in the shoulder area that contribute to arm elevation, internal rotation and external rotation. Of the teres muscle group, it is the teres minor, not teres major that is part of the rotator cuff. The scalene muscles are in the neck and cause rib elevation and neck movement. The soleus muscles cause plantar flexion of the feet and are located in the calf area of the posterior lower leg.

Which fluid should never be used to replace volume?

D5W (5% dextrose)

A teenage girl presents to the emergency department with her parents. She has had symptoms of a urinary tract infection for the last two days, but did not tell her parents until today. She is not sexually active. Today, the girl also has diffuse abdominal pain with vomiting, general malaise, and difficulty breathing. She has no significant past medical history. Her physical exam reveals sinus tachycardia and deep fast respirations with no localization of abdominal pain or rebound tenderness. Initial lab test results reveal a plasma glucose = 378 mg/dL and serum bicarbonate = 14 mEq/L. What is the most likely diagnosis? A Hyperosmolar nonketotic hyperglycemia B Diabetic ketoacidosis C Chronic corticosteroid use D Gestational diabetes E Schmidt syndrome

DKA The correct choice is B, diabetic ketoacidosis (DKA). Classic signs and symptoms of this disorder include polyuria, polydipsia, marked fatigue, nausea, vomiting, signs of dehydration, fruity breath odor, postural hypotension, Kussmaul respirations, and possibly mental stupor or coma. Patients with type 1 diabetes mellitus may present for the first time in DKA. DKA is commonly precipitated by a recent infection. Choice A, hyperosmolar nonketotic hyperglycemia, is seen in patients with type 2 diabetes and presents with extremely high plasma glucose levels without acidosis and ketosis. Choice C, chronic corticosteroid use, can cause hyperglycemia and possible glucose intolerance or diabetes mellitus. This patient has no history of oral corticosteroid use. Choice D, gestational diabetes, occurs in women who are pregnant. Choice E, Schmidt syndrome, is an autoimmune polyglandular syndrome which includes diabetes mellitus in greater than 50% of patients.

What are the common causes of hypoglycemia?

DM patient taking either: -Insulin -Sulfonylureas (glipizide, glyburide, chlorporpamide)

The FAST exam is trauma has replaced what technique for examining hemodynamically unstable patients?

DPL - diagnostic peritoneal lavage

______is acute inflammation of the lacrimal gland. Tx: observed and treated with abx if needed. Superior temporal region. ______is infection of the lacrimal gland. Tx: antibiotics and relief of the obstruction. Inframedial region.

Dacryoadenitis; Dacryocystitis

Scuba diver ascends and has mottled skin and arthritis in shoulder and knee that is not affected by movement. Dx and tx.

Decompression sickness Type 1 -100% oxygen -IV fluids -Recompression therapy (hyperbaric oxygen) -Lidocaine

Scuba diver ascends and has truncal constriction (feels tight around chest) and ascending paralysis. Dx and tx.

Decompression sickness Type 2 -100% oxygen -IV fluids -Recompression therapy (hyperbaric oxygen) -Lidocaine

Pt present to the ER for a burn. It has pink hemorrhagic markings, involves the epidermis and dermis, is moist and painful. What kind of burn is it and how long does it take to heal?

Deep second degree burn....takes 3-4 weeks to heal

Infant with sunken fontanelles, decreased capillary refill, no tears, decreased wet diapers. Dx and tx.

Dehydration -D51/2NS

Fever, headache, urticaria, lymphadenopathy, and arthritis many days after stung by insect. Dx and tx.

Delayed reaction to Hymenoptera -EPI IM -Normal saline -Diphenhydramine -Steroids -Albuterol (if bronchospasm) -Prescribe EPI Pen

What pressure is used to diagnose compartment syndrome?

Delta pressure (diastolic pressure minus tissue pressure) < 30

Recent travel with high fever, headache, N/V, myalgia followed by a rash. Dx and tx.

Dengue Fever -Avoid aspirin and NSAIDs -Monitor for hemorrhagic symptoms -Supportive tx

_____is due to deficiency of or resistance to vasopression/anti-diuretic hormone. S/S are intense thirst, polyuria, dehydration. Treatment is with what?

Diabetes Insipidus; desmopressin acetate (and possibly HCTZ)

A 23-year-old man, unrestrained driver, is brought to the emergency department by ambulance after having been involved in an automobile accident. His vitals are BP: 99/54 mm Hg, P: 112/min, R: 18/min, oxygen saturation: 99%, T: 99.8°F. Examination reveals mild abdominal tenderness with pain radiating to the right shoulder. What is the most appropriate diagnostic test to order initially? A Computed tomography of the abdomen and pelvis B Diagnostic peritoneal lavage C Flat and upright abdominal radiographs D Diagnostic ultrasound

Diagnostic u/s The initial evaluation of blunt abdominal trauma is by the performance of a FAST (focused assessment with sonography for trauma) ultrasound, which is performed by an emergency department physician or surgeon. CT scan remains an adjunct test in hemodynamically stable patients or in patients in whom further assessment of solid intra-abdominal organs is required.

What is the MC type of cardiomyopathy? What the MC causes of cardiomyopathy? What are the symptoms? What imaging should be ordered and what is seen? What are the 5 tx?

Dilated MI, infection SOB, DOE, hypoxia CXR, Echo, EKG all show CHF signs...*kerley-B lines Diuretics, ACE, Vasodilators, BB, anticoag

Simultaneous hemorrhage and thrombosis is characteristic of...

Disseminated Intravascular Coagulation

Petechiae, diffuse hemorrhages, altered mental status, oliguria, focal ischemia. Dx and tx.

Disseminated Intravascular Coagulation -Tx underlying illness -IV fluids -Cryoprecipitate -Platelets -FFP -Vit K

What do we to treat restrictive pericarditis?

Diuretics and surgery (typically patient has JVD, and appear quite ill)

What is the most useful factors in diagnosing dysbarism?

Dive profile: -Depth -Duration -Repetitiveness

Trauma to the abdomen and then slow onset of abdominal pain, fever, N/V. Dx.

Duodenal injury

How is VVC diagnosed? Treatment?

Dx: KOH shows yeast buds Tx: Nystatin, miconazole, or clotrimazole

How is bacterial vaginosis diagnosed? Treatment?

Dx: fishy odor, increased vaginal discharge, elevated pH, and clue cells Tx: Metronidazole

How is Trichomonas diagnosed? Treatment?

Dx: yellow-green d/c, elevated pH, saline prep shows flagellated trichomonads Tx: Metronidazole

Complications associated with changes in environmental pressure and with breathing compressed gas is known as...

Dysbarism

Acute Coronary syndrome hx of symptoms includes...

Dyspnea, diaphoresis, n/v, tachy/brady cardia, jawk/neck/shoulder pain

A 22-year-old recent immigrant from Vietnam, who is 28 weeks pregnant with her first child, presents to the emergency department with complaints of worsening dyspnea and lower extremity edema. She is unable to answer definitively whether or not she has a history of rheumatic fever. On physical examination, a possible opening snap, loud S 1 , and a very soft diastolic rumbling murmur is auscultated. When the patient is placed in the left lateral decubitus position, the murmur is accentuated, and heard best at the apex. With inspiration, the murmur does not increase in amplitude. Which of the following is the most likely finding on echocardiogram? A Tricuspid regurgitation B Tricuspid stenosis C Atrial septal defect D Aortic regurgitation/insufficiency E Mitral stenosis

E Choice E, mitral stenosis, is the most likely finding in this patient, who presents with physical exam findings including a possible opening snap, loud S 1 , and a very soft diastolic rumbling murmur which is heard best at the cardiac apex and accentuated by placing the patient in the left lateral decubitus position. Although rheumatic fever was not positively confirmed, the patient likely did have a history, given that the majority of cases of mitral stenosis are secondary to rheumatic heart disease. Patients from Asia, Central America, and South America are exposed more frequently than their counterparts in more developed countries, where antibiotic use is more common. Choices A and B, tricuspid regurgitation and tricuspid stenosis, are also linked with patients with rheumatic heart disease. The murmur of tricuspid regurgitation, however, is a systolic murmur, which increases with inspiration and is heard best at the left lower sternal border. Tricuspid stenosis presents with a diastolic murmur, and with inspiration the murmur increases. It, too, is heard best at the left lower sternal border. Choice C, an atrial septal defect, if large, could present with similar symptoms of exertional dyspnea secondary to a large shunt, but auscultation would reveal a moderately loud systolic ejection murmur that is heard best in the second and third interspaces. This is secondary to increased pulmonary arterial flow. Choice D, aortic regurgitation/insufficiency, is also a diastolic murmur; however, it is usually a diastolic decrescendo murmur that is heard best at the left sternal border.

Vomiting, stomach cramps, bloody diarrhea, mild fever. Dx and tx.

E Coli (STEC = shiga producing toxin e. coli) -Rehydration -Metoclopramide or Ondansetron (for vomiting) -Abx are contraindicated in patients with STEC

Which of the following indicates EKG changes consistent with a suspected pulmonary embolus? A Increased QRS amplitude with tall R waves in limb leads and deep S waves in V1 and V2 B Notched P wave in leads I and II with an increased duration C Prolonged PR interval with peaked T waves D Prolonged QRS duration with QS complex in V1, monophasic R wave in leads I and V6 E Sinus tachycardia with a right ventricular strain pattern, prominent S in lead I, Q wave and inverted T in lead III

E Sinus tachycardia with a right ventricular strain pattern, prominent S in lead I, Q wave and inverted T in lead III Approximately 70% of patients with a pulmonary embolus will demonstrate EKG changes. The changes present may range from sinus tachycardia to findings consistent with marked right heart strain and dilatation. The correct answer also includes the classic "S1Q3T3" pattern of changes associated with pulmonary embolism. The findings in choice A are consistent with left ventricular hypertrophy. Choice B is indicative of left atrial enlargement. Choice C is consistent with hyperkalemia. Choice D indicates left bundle branch block. These changes are not commonly associated with pulmonary embolism.

GLASCOW COMA SCALE

EYE OPENING 4 - spontaneous 3 - open to speech 2 - open to pain 1 - no response VERBAL 5 - alert and oriented 4 - disoriented conversation 3 - inappropriate words 2 - nonsensical sounds 1 - no response MOTOR 6 - spontaneous 5 - localizes pain 4 - withdraws to pain 3 - decorticate posturing 2 - decerebrate posturing 1 - no movement

What are the symptoms of early hypothermia? late hypothermia?

Early (32-35 C) -Shivering -Tachycardia -Tachypnea -HTN Late (<32) -No shivering -Bradypnea -Bradycardia -Hypotension -Confusion -Lack of reflexes

Decelerations of fetal heart monitoring: ____decelerations begin and end at the same time as the contraction. ____decelerations occur at any time and drop more than early or late decelerations. Result of umbilical cord compression. ____decelerations begin at peak of a contraction and slowly return to baseline after the contraction is complete. Uteroplacental compromise.

Early; Variable; Late

Bit by a snake. Tremor, salivation, seizures, diplopia, dysphagia, bulbar palsies. Dx and tx.

Eastern Coral Snake bite (only type of coral snake that is bad) -Consult poison control -Antivenom -Admit

Tick bite, fever, malaise, N/V, diarrhea, arthralgia, leukopenia, thrombocytopenia, liver abnormalities. Dx and tx.

Ehrlichiosis -Doxycycline

Most common CNS complication of infective endocarditis?

Embolic stroke in MCA

Tx for tibial fracture?

Emergent ortho consult

_____is a condition defined pathologically as dilation of the air space distal to the terminal brochiole with destruction of the interalveolar septa. "pink puffer" CXR - hyperinflated with flat diaphragms

Emphysema

____is infection of the brain parenchyma. CSF: Gram stain usually negative, WBC majority is mononuclear leukocytes, protein >100, CRP normal, glucose normal to slightly decreased.

Encephalitis

____is the presence of endometrial tissue outside the endometrial cavity. S/S: dyspareunia, infertility, abnormal bleeding, and chronic pelvic pain. Dx: direct visualization w laparoscopy

Endometriosis

Intense perianal itching in a child. Dx and tx.

Enterobiasis pinworm -Mebendazole

Lice infested followed by high fever, severe headache, maculopapular rash starting in axillae. Dx and tx.

Epidemic Typhus (Rickettsia Prowazekii) -Doxycycline

______hematoma often presents with spinal fluid rhinorrhea and unconsciousness followed by resolution and then later unconsciousness AFTER a skull fracture.

Epidural

_____is inflammation or infection of supraglottic structures ie. tongue, vallecula, arythenoid, and tonsils. What age is most commonly affected?

Epiglottitis; between 2 and 6 years old

A patient presents with enlarged tonsils, exudates, and petechiae of the palate...what organism?

Epstein-Barr

Sudden high fever, malaise, nausea. Followed by a small, well demarcated, tense, burning area on legs. Lymphangitis. Dx and tx.

Erysipelas -Ceftriaxone IM + penicillin po

____is infection of the dermis with lymphatic involvement. More superficial that cellulitis; typically more raised and demarcated. Possible red, painful streaks of lymphangitis. Tx: Pen V, Amox, Azith, Clarith

Erysipelas - St. Anthony's fire

A fisherman develops marginating plaques after cutaneous puncture wounds from handling the fish. Dx.

Erysipelothrix rhusiopathiae

Fever, malaise, generalized burning and pruritus followed by papules/macules followed by target lesions. Dx and tx.

Erythema Multiforme -Prednisone -Outpatient follow-up

Intubation complication???

Esophageal intubation NOT: Right mainstem bronchus

A pt with little known history was found by a stranger as tachycardic, febrile, diaphoretic. PE reveals subcutaneous emphysema. Hamman's crunch is also noted. What is the likely diagnosis and test of choice?

Esophageal rupture Get a CT with water soluble contrast

A 21-year-old man presents to the emergency department complaining of a swollen left ear (see image) after he experienced blunt trauma in a collegiate wrestling match. Which of the following is the most appropriate management for this condition? Picture of an auricular hematoma. A Evacuation B Evacuation followed by antibiotics C Evacuation with subsequent antibiotics and splinting D Ice and compression E Reevaluation in 24 hours

Evacuation with subsequent antibiotics and splinting The patient has an auricular hematoma that must be evacuated to prevent cartilage necrosis or infection. Evacuation, antibiotics, and splinting (C) remove the hematoma, minimize the risk of infection, and help prevent the re-accumulation of blood.

Pruritis, tightening of the skin, flaking and scaling of skin, exfoliation of skin. Low grade fever. Thinning hair and dystrophic nails. Dx and tx.

Exfoliative Erythroderma -Emergent derm consult -Look for cause of hypersensitivity reaction (drug, chemical, underlying systemic disease)

A disk herniation that is putting pressure on the L5 nerve root may present with weakness of what muscle(s)? A Anterior tibialis B Extensor hallucis longus C Gastrocnemius-soleus D Iliopsoas E Peroneus longus and brevis

Extensor hallucis longus The extensor hallucis longus muscle's motor function is associated the L5 motor neuron, which also supplies the gluteus medius and extensor digitorum longus and brevis muscles. The anterior tibialis muscle is supplied by the L4 motor neuron. Nerves emanating from T12, L1, L2 and L3 supply the iliopsoas. Gastrocnemius, soleus and peroneus longus and brevis are all supplied by nerves coming from the S1 area. The plantar flexing gastrocnemius and soleus muscles also are supplied by S2.

What are the 4 levels of eye opening in the Glasgow Coma Scale?

Eye opening: 4 = spontaneous 3 = in response to speech 2 = in response to pain 1 = no response

A 3 year-old boy is brought to the emergency department due to acute onset of cough and wheezing. Physical exam reveals focal wheezing in the right lower lobe. Which of the following is the most likely diagnosis? A Asthma B Bronchiectasis C Epiglottitis D Foreign body aspiration E Vocal cord dysfunction

FB aspiration The acute onset of symptoms and their localization to the right lower lobe are consistent with foreign body aspiration (D). Asthma (A) presents with diffuse wheezing. Bronchiectasis is less common in this age group and typically presents with a copious amount of sputum production. Epiglottis (C) and vocal cord dysfunction (E) present with upper airway symptoms.

Low sodium (Na < 135) and normal/high serum osmolality (275-295 or higher). Dx and causes.

Factitious hyponatremia -Hyperglycemia (high osmolality) -Hyperproteinemia (normal osmolality) -Hyperlipidemia (normal osmolality)

What three things are hypercoagulable states that increase risk of DVT?

Factor V Leiden; cancer; HELLP (hemolysis, elevated liver enzymes, and low platelets in pregnancy)

Hemophilia A is treated with ________. Hemophilia B is treated with ________. vonWillebrand disease is treated with ___or___.

Factor VIII; Factor IX; vW factor or DDAVP

What clotting factors are Vitamin K deficient?

Factors II, VII, IX, or X

What is pathognomonic for a lighting strike injury?

Feathering/fern-shaped burn on the skin

A 2-year-old child presents to the emergency department via ambulance due to a seizure lasting approximately 2 minutes with jerking and somnolence. En route in the ambulance her vital signs are: temperature 39°C rectal; pulse 120/min; respirations 32/min; blood pressure 110/64 mm Hg. Upon further questioning, her mother claimed she had a runny nose yesterday. On physical examination, she is sleepy but arousable with negative Kernig and Brudzinski signs. Which of the following seizures is the MOST likely diagnosis? A absence seizure B complex partial seizure C febrile seizure D simple partial seizure

Febrile Seizure C A febrile seizure is a brief (less than 15 minutes), generalized, symmetric, tonic-clonic seizure associated with a febrile illness (temperature greater than 38.8°C) without any central nervous system infection or neurologic cause. An absence (petit mal) seizure is a brief (2 to 25 seconds) loss of consciousness that can occur multiple times per day. There is no loss of tone, and frequently the only observable behaviors are staring or minor movements such as lip smacking and semipurposeful movements of the hands. There is no postictal period. Complex partial seizures (psychomotor) have varied symptoms including alterations in consciousness, unresponsiveness, and repetitive complex motor activities that are purposeless. Often, at the beginning of the attack, there is a psychoillusory phenomenon such as hallucinations, visual distortions, visceral sensations, or feelings of intense emotions. Simple partial seizures include focal motor, adversive, and somatosensory seizures. Manifestations of these seizures are varied including hallucinatory, psychoillusory, or complex emotional phenomena. Children will interact normally with their environment, with the exception of those limitations imposed by the seizure. Following the seizure (minutes to hours), there may be transient paralysis of the affected body part.

What is the most commonly indicated test for patients presenting with signs of foodborne illness (i.e., diarrhea)?

Fecal occult blood

An 8-month-old female is diagnosed with respiratory syncytial virus bronchiolitis while in the emergency department. Which of the following strongly indicates a need for admission to the hospital and continued monitoring? A Age of 8 months B Birth at 38 weeks C Feeding difficulty with decreased oxygen saturation D Oxygen saturation of 96%

Feeding difficulty with decreased O2 sat C Brochiolitis patients must be considered at risk of developing severe disease and/or apnea when certain criteria are present, thus requiring admission. This includes, but may not be limited to, the following: birth <37 weeks gestation, age <12 weeks, witnessed apnea, underlying cardiopulmonary disease, immunodeficiency, tachypnea based on expected respiratory rate per age, decreased oral intake or feeding difficulty with associated decreased oxygen saturation, decreased oxygen saturation with varying ranges based on source (most being <95%), a history of previous intubation, and a caregiver ability to adequately provide care and monitoring.

Shortened, deformed, painful, swollen leg after a motor vehicle accident. Dx and tx.

Femur fracture -Splint with traction -Emergent ortho consult

A 40- year-old female patient comes to the office because she notices that she is easily fatigued but cannot pinpoint a direct cause of her fatigue. She has experienced muscle tenderness to the shoulders and other large muscle groups, sensitivity to touch these areas, and has also felt depressed lately. Based on this history and the vague physical exam findings, what is the most likely diagnosis? A Fibromyalgia B Polyarteritis nodosa C Polymyositis D Scleroderma

Fibromyalgia A Fibromyalgia syndrome (FMS) primarily affects woman between the ages of 20 and 60 and is now the second most common condition seen in rheumatologists' offices behind only rheumatoid arthritis. This condition spares the joints, but causes tender areas throughout the soft tissue as well as generalized pain and fatigue. There are several common trigger points, both anteriorly and posteriorly that help confirm the diagnosis. Polyarteritis nodosa is a systemic necrotizing vasculitis that generally affects medium size muscular arteries. Patients can present with many of the same symptoms as those with fibromyalgia (fatigue, muscle pain, and others), but these patients often have skin manifestations, joint pain, and fever, along with renal, GI, and cardiovascular signs not seen in fibromyalgia. Polymyositis is an inflammatory condition of the muscles that is characterized by proximal muscle weakness, with much less pain than is seen in fibromyalgia. Despite the proximal muscle weakness there is generally not significant atrophy. Sjogren's syndrome does not generally present with any muscular manifestations. It is a chronic inflammatory disorder that affects the salivary and lacrimal glands resulting in dry eyes and a dry mouth. Scleroderma is classically associated with thickened and hardened skin, but it can have internal organ involvement as well affecting many different body systems. When it affects the musculoskeletal system it tends to affect joints and the areas where tendons cross joints. It can cause contractures, pain, and swelling as well as fatigue and weakness

BLOCKS 1. ____=prolonged PR interval 2.____=progressive increase in PR until Pwave is blocked. 3._____=sudden block in P wave w no change in PR 4._____=atrial and ventricular rhythm are independent of each other.

First degree; Wenckebach Mobitz type I; Mobitz type II, Third degree block

What are the first and second line agents for seizure -- after establishing patent airway and reversing any metabolic causes?

First-line --- benzos Second-line --- phenytoin/fosphenytoin

Zig-zag lines of lesions with hemorrhagic puncta with are intensely itchy. Dx and tx.

Flea bites -Calamine lotion -Cool soaks -Antihistamines

Acute Mountain Sickness: 1 Hallmark

Fluid retention

How do we treat infectious diarrhea?

Fluids Oral rehydration Loperamide- antidiarrhea Zalderide maleate-anti secretory

How do we treat gastroenteritis?

Fluids or do nothing

What is the treatment for a splenic rupture?

Fluids, NGT, NPO with nutritional support via post pyloric feeding. Abx and meperidine for pain (morphine should be avoided Surgery when necrotic

How do we treat Stephens Johnson Syndrome?

Fluids, parental nutrition with lots of protein Steroids, plasmaphoresis, immunosupressive therapy and IVIG have had mixed results

Antidote → Benzos

Flumazenil

Which drugs place a person at high risk for achilles tendon injury?

Fluoroquinolones (particularly Levo)

Describe pain location, type, radiation, and other ss with... PE

Focal chest pain that is pleuritic with tachypnea and tachyhardia and possibly hemoptysis

Renal artery thrombosis is associated with which fracture?

Fracture at L2 vertebrae

What is a Chance fracture? What is the MOI?

Fracture through all three vertebral columns MOI: -Intraabdominal injury -"Seatbelt" injury

The ________principle means that as preload increases, the ventricle is stretched during diastole filling and the ejection fraction is increased.

Frank-Starling principle

The Cerebrum lobes and functions: ____=voluntary motor function, verbal communication, personality, and judgement ____=general sensory functions ____=hearing and smell ____=visual information and story visual memories Broca is motor speech area. Wernicke is comprehending spoken or WRITTEN language.

Frontal Lobe; Parietal Lobe; Temporal Lobe; Occipital Lobe

Heinz bodies indicate...

G6PD

What is the most common enzymopathy of RBCs?

G6PD

Distal radius fracture with radialulnar joint dislocation at the wrist. Dx and tx.

Galeazzi fracture -Refer for ORIF (open reduction and internal fixation)

Treatment for CMV?

Ganciclovir

A 46-year-old female presents with pain to her left wrist. She complains that it is painful and swollen as she points to the volar aspect of the wrist on the radial side. On examination, there is a small, soft bump on the dorsum of her wrist with a jelly-like consistency. What is the most likely diagnosis? A Cancerous tumor B Fracture C Ganglion cyst D Hematoma E Lipoma

Ganglion Cyst C Ganglion cysts commonly occur on the dorsal or volar aspect of the wrist. They result when a joint capsule or tendon sheath is damaged, allowing synovial fluid to escape producing a one-way valve, which allows fluid into the cyst, but not back out. The accumulating fluid forms the ganglion cyst. These cysts may or may not be tender and can fluctuate in size depending on activity level of the affected extremity. Cancerous tumors would tend to be much more firm, but also may be relatively pain free. Fractures would generally be exquisitely tender and if the bump is due to a displaced bone, it would be much more firm than a ganglion cyst. Hematomas are generally associated with acute trauma and would be tender and ecchymotic in many situations. Lipomas are benign fatty tumors that are more commonly seen on the thenar eminence than the dorsum of the wrist and their size does not change based on activity level.

Painless lump on wrist. Had same thing last year, but went away.

Ganglion cyst (bible)

What is the most common form of tetanus?

Generalized

____seizures (ie. abnormal excessive cortical neuron activity) are thought to originate from both cortical hemispheres resulting in loss consciousness and tonic-clonic muscle contractions.

Generalized seizures

Systemic corticosteroids can have what negative effect on the eye?

Glaucoma

______is an uncommon cause of acute renal failure due to immune complex deposits in the kidney. Dysmorphic RBC and RBC CASTS are common.

Glomerulonephritis

What is the criteria for diagnosing DKA? Glucose, HCO3, pH, Sodium, Potassium

Glucose >250; HCO3<15; pH<7.2; sodium low; potassium may show as normal or slightly elevated but total body potassium is usually depleted by renal losses

Most common cause of acute arthritis in young adults?

Gonoccocal joint infection

Most common cause of infectious arthritis in young adults?

Gonorrhea

Sexually active man with dysuria and purulent penile discharge. Dx.

Gonorrhea

Sexually active woman with lower abdominal pain, mucopurulent vaginal discharge, and cervicitis. Dx.

Gonorrhea

What symptom is vaginal purulent discharge caused by?

Gonorrhea

STD antibiotic treatment Gonorrhea? Chlamydia? Syphillis? Genital Herpes? Genital Warts?

Gonorrhea - ceftriaxone; cefixime Chlaymydia - azithromycin; doxycycline Syphillis - Penicillin G; doxycycline Genital Herpes - acyclovir; valcyclovir Genital Warts - Imiquod cream, Gardisil VACCINE

Epididymitis or infection of the epididymis is often divided into two groups based on age distribution: 1. <40 years old is usually from ____ 2. >40 years old is usually from ____.

Gonorrhea or Chlamydia; gram negative rod from UTI or prostatitis

What indicates a good prognosis for mushroom poisoning? Poor prognosis?

Good = if symptoms start within 2 hours of ingestion Poor = if symptoms (esp. vomiting/diarrhea) don't start for more than 6 hours after ingestion (indicates liver failure)

What are the grades for sprains?

Grade 1 = incomplete tear (stable) Grade 2 = significant incomplete tear (some laxity) Grade 3 = complete disruption (unstable)

Concussion grading - American Academy of Neurology: ____=confusion but no LOC for <15 minutes. ____=confusion but no LOC for >15 minutes. ____=LOC either brief or prolonged.

Grade 1, Grade 2, Grade 3

What will a gram stain of gonorrhea show?

Gram negative diplococci

What is the most common organism causing Septic Shock?

Gram negative rods

What ankle-brachial index levels correspond to what? How do we treat therpaeutically? How do we treat surgically?

Greater than 1 is normal .88-.99- mild .4-.79- Claudication <.4 is ischemic TX with compression stockings, Cilo, pento Sx with endovascular graft or bypass

A 9-year-old female presents to the emergency department after falling out of a second story window. Imaging of the left upper extremity shows the following fracture pattern: How would this fracture be described? A Transverse B Oblique C Spiral D Segmental E Greenstick

Greenstick A greenstick fracture occurs almost exclusively in young children as a result of their bones being more pliable than those of adults. On imaging, a greenstick fracture has cortical disruption on the convex side of the bone with an intact periosteum on the concave side of the fracture. Spiral fractures (C) are often seen in non-accidental or child abuse cases. Transverse (A), segmental (D), and oblique (B) fractures involve both cortices.

Organism that causes Erysipelas?

Group A Strep

Patient presents with erythematous pharynx, enlarged tonsils, and yellow-white exudate...organism?

Group C strep

_____is most likely due to an immune-mediated mechanism --- due to lymphocytic infiltration and macrophage-mediated demyelination and axonal degeneration. Campylobacter, mononucleosis, CMB, herpes, mycoplasma

Guillain-Barre

What is the PERC score? HADCLOTS

H - hormone/estrogen use A - age>50 D - dvt/pe history C - coughing blood L - leg swelling disparity O - O2 sat < 95% T - tachy>100 S - surgery/recent trauma

What is the criteria for the PERC SCORE????? HADCLOTS This is used to rule out the need for further imaging.

H - hormone/estrogen use A - age>50 D - dvt/pe history C - coughing up blood L - leg swelling disparity O - O2 sat<95 T - tachy>100 S - surgery/recent trauma

The most common pathogens of epiglottitis are Strep pyrogenes, Strep pneumo, and Staph aureus. Which vaccine has dropped the incidence of epiglottitis? Class lateral neck radiograph finding?

HIB; "thumb print" sign

A 23-year-old man presents to the outpatient clinic for follow-up from a recent urgent care visit. He complains of sore throat, fever, fatigue, myalgias, and a rash that started 5 days ago, and have worsened since he was seen in the urgent care 3 days ago. The patient appears non-toxic with a temperature of 39.4 degrees Celsius. Physical exam reveals pharyngeal and tonsillar erythema without exudates, generalized lymphadenopathy, a morbilliform rash on his trunk, and no hepatosplenomegaly. A rapid strep screen and Monospot performed at the local urgent care were reportedly negative. Which of the following laboratory tests is most likely to confirm the expected diagnosis? A Complete blood count B Cytomegalovirus titer C Group A beta-hemolytic strep culture D HIV viral load E Epstein-Barr virus titer

HIV viral load The patient presentation is consistent with acute retroviral syndrome, which is best confirmed during this initial presentation phase through direct testing for the HIV virus, such as an HIV viral load (D). The lack of tonsillar exudates, a negative monospot, and presence of generalized adenopathy make infectious mononucleosis (B and E) less likely. A CBC (A) may show lymphopenia and support the diagnosis, but it doesn't confirm the diagnosis.

What is the most common viral cause of encephalitis in the US?

HSV 1

1/3 of all trauma related deaths are due to what injury?

Head trauma

What are three scoring systems, in addition to TIMI and GRACE, that help guide treatment of possible acute coronary syndrome patients? What is considered high risk in the system beginning in H?

Heart, ADAPT, North American Chest Pain rule

Painful muscle spasms during athletic events. Dx and tx.

Heat cramps -Rest -Rehydration and electrolyte replacement (gatorade)

Mild swelling of hands and feet after being in new hot environment. Dx and tx.

Heat edema -Elevate extremities -Compressive stockings

Vesiculopapular eruption over clothed areas of the body in a hot environment. Dx and tx.

Heat rash (due to obstructed sweat ducts) -Antihistamines -Calamine lotion -Low potency corticosteroids -Wearing loose fitting clothes

Person coming in from extreme heat has hyperthermia, altered mental status, confusion, bizarre behavior, seizures, hyperventilation, N/V, diarrhea, muscle cramps, oliguria. Dx and tx.

Heat stroke -Evaporative cooling (fans and sprayed with water) = most efficient means of cooling -Oxygen -IV crystalloids -Intubation if altered mental status, diminished gag reflex, or hypoxic -Admit to ICU

Heat edema; heat rash; heat cramps; heat syncope; heat exhaustion; heat stroke. ______is a life-threatening form of heat illness that typically occurs in patients with core temperatures greater than 41C/106F. What is the preferred method for rapid cooling.

Heat stroke; ice water immersion

Hyperventilating person in intense heat with extremity and circumoral parasethesia and carpopedal spasm. NO muscle cramps. Dx and tx.

Heat tetany -Removal from intense heat

Deficiency in factor 8 is...

Hemophilia A

Deficiency in factor 9 is...

Hemophilia B

Which Hepatitis are transmitted by fecal-oral route? parenteral/sexual route?

Hep A&E - fecal-oral Hep B,C,D - parenteral/sexual

Which Hepatitis must you have in order to get Hepatitis D?

Hep B

Platelet count drops > 50% a week after starting heparin. Dx and tx.

Heparin-Induced Thrombocytopenia -Stop heparin -Consult hematologist

Which Hepatitis can become chronic?

Hepatitis B, C, D

Back pain with positive crossed straight leg test and diminished reflexes. Dx.

Herniated disc

A 35 year-old female presents with multiple ulcerative lesions on her labia and perineum. A Tzanck preparation of one of the lesions reveals multinucleated giant cells. Which of the following is the most likely diagnosis?

Herpes Simplex Virus Giant multinucleated cells are indicative of HSV

Pain followed by erythematous papules on a unilateral dermatone that turned to vesicles and crusted. Dx and tx.

Herpes Zoster -Acyclovir (if immunocompromised or within 72 hours of onset) -Analgesics -Ophthamology consult if close to eye

Acute onset of fever, focal motor deficits, CN abnormalities, ataxia, seziures, behavioral abnormalities, WBCs in CSF, temporal lobe lesions on CT. Dx and tx.

Herpes encephalitis -Acyclovir

Painful grouped vesicles on an erythematous base. Dx and tx.

Herpes simplex -Tzanck smear -Acyclovir

Rapid ascent to higher elevation. A couple days later, altered mental status, ataxia, stupor, occulomotor and abducens nerve palsies. MRI with increased signaling in splenium of corpus callosum. Dx and tx.

High Altitude Cerebral Edema -Immediate descent -Oxygen -Dexamethasone

Rapid ascent to higher elevation. A couple days later, dry cough that then turns productive, dyspnea, severe weakness, cyanosis, tachycardia, rales, right ventricular heave, right axis deviation on EKG. Low O2 sat. Dx and tx.

High Altitude Pulmonary Edema -Immediate descent = tx of choice -Oxygen -Nifedipine or Sildenafil or Tadalafil

What are common fractures associated with shoulder dislocation?

Hill-Sachs lesion = impaction of the posterior lateral humeral head Bankart fracture = detachment of labrum from glenoid

Pain in knee and groin, shortened leg that is externally rotated in an elderly person after a fall. Dx and tx.

Hip fracture -Ortho consult

Trauma to the abdomen and then signs of blood loss and peritoneal contamination. Dx.

Hollow visceral organ injury (stomach, small bowel, colon)

_______sign is pain with dorsiflexion of the foot. May be positive with DVT.

Homan's

A patient has been triaged with chest pain, but exam/labs have ruled out MI. What findings in the hx might we find with someone who has GI induced chest pain? What treatment might provide relief in both these causes as well as MI?

Hot or cold drinks in excess, large food bolus,. Nitroglycerine

Pain, swelling, tenderness, ecchymosis, and crepitus around the shoulder in an elderly individual who fell. Dx and tx.

Humerus fracture -Coaptation splint (sugar tong)

An 85 y/o with multiple myeloma and lung cancer presents with back pain, altered mental status, and constipation. What is the likely serum change?

Hypercalcemia

Renal stones, bone aches, lethargy, weakness, constipation, polyuria. ST depression, widened T waves, shortened QT, heart block. Electrolyte imbalance dx and tx.

Hypercalcemia -NS (main goal is hydration) -Furosemide (after dehydration corrected)

Calcium Channel Blocker OD: Effect on blood sugar?

Hyperglycemia

Weakness, paralysis, N/V, diarrhea, colic. Peaked T-waves, prolonged PR, short QT, wide QRS. Electrolyte imbalance dx and tx.

Hyperkalemia Steps: 1. IV Calcium chloride or Calcium gluconate 2. Insulin + glucose 3. Kayexalate diuretic

Digoxin inhibits the membrane-bound sodium potassium-ATPase ion exchanger. Dig toxicity is made clinically and typically relies on history. ______greater than 5mEg/L and significant dysrhythmias warrant administration of Digibind. What EKG findings?

Hyperkalemia; PVC's, atrial tachycardia w AV block, a fib

N/V, obtundation, muscle weakness, absent DTRs, hypotension, heart block. Electrolyte imbalance dx and tx.

Hypermagnesemia -Stop taking lithium or antacids -IV calcium chloride (if severe)

Polydipsia (thirst), irritability, tremulousness, ataxia, lethargy. Electrolyte imbalance dx and tx.

Hypernatremia -NS or lactated ringers -Furosemide + 1/2NS (if NS doesn't work) -Desmopressin (if central DI)

New onset DM Type 2 often present with what disorder?

Hyperosmolar Hyperglycemic State

Weakness, altered mental status, dehydration, polyuria, polydispsia, tachycardia, hypotension, glucose > 600, NO kussmaul respiration, NO fruity breath. Dx and tx.

Hyperosmolar Hyperglycemic State -Isotonic Saline -Potassium (if < 3.3) -Insulin

Pt w a hx of one syncopal episode presents with midsystolic murmur that is reduced by squatting and increased with straining...diagnosis?

Hypertrophic cardiomyopathy

___refers to blood in the anterior chamber of the eye -- management includes keeping the head elevated, limiting eye movements, prescribing analgesics, and avoiding use of anticoagulants or antiplatelet medications. Results from torn blood vessels within the iris and ciliary body.

Hyphema

Oral parasthesia, increased DTRs, cramps, weakness, confusion, seizures, chvostek sign, trouseau sign. Prolonged QT. Electrolyte imbalance dx and tx.

Hypocalcemia -Calcium gluconate + magnesium

What is the treatment for hypocalcemia and hypercalcemia?

Hypocalcemia -- oral Ca for asymptomatic pt; IV Ca for symptomatic patients Hypercalcemia -- IV isotonic saline and IV furosemide

What is the EKG findings in hypocalcemia and hypercalcemia?

Hypocalcemia -- prolongation of QT interval; inverted T waves Hypercalcemia -- shortening of QT interval; prolongation of PR interval

β-blocker OD: Effect on blood sugar?

Hypoglycemia

Diabetic patient with confusion, seizures, sweating, anxiety, nausea, dizziness, blurred vision, lethargy, headache. Dx and tx.

Hypoglycemia -50% dextrose 50 mL IV -Glucagon (if no IV access) -Blood glucose every 30 minutes -Admit if due to sulfonylureas

Weakness, hyporeflexia, paresthesia, constipation, U waves. Electrolyte imbalance dx and tx.

Hypokalemia -Stable = oral K+ -Unstable = IV potassium chloride

Depression, vertigo, nystagmus, ataxia, seizures, dysphagia, hypothermia. Increased DTR. Prolonged PR, wide QRS, prolonged QT. Electrolyte imbalance dx and tx.

Hypomagnesemia -Oral magnesium -IV magneisum sulfate (if severe + good kidney function)

What electrolyte imbalance is seen with torsad de pointes?

Hypomagnessemia

N/V, weakness, headache, agitation, hallucinations, cramps, confusion, seizures. Electrolyte imbalance dx and tx.

Hyponatremia If hypovolemic: NS If euvolemic or hypervolemic: fluid restriction If severe hyponatremia (<120): hypertonic saline

Which of the following is a cause of prerenal azotemia?

Hypoperfusion which is EASILY correctable

What are the three most indicative PE findings in MI?

Hypotension, diaphoresis, s3 gallop

Low sodium (Na < 135) and low serum osmolality (<275) with no signs of dehydration or volume retention. Dx and causes.

Hypotonic Euvolemic hyponatremia -SIADH -Stress/Pain -Adrenal Insufficiency (Addisons) -Myxedema (Hypothyroidism) -Sheehan syndrome -Drugs -Water intoxication

Low sodium (Na < 135) and low serum osmolality (<275) and edema and increased JVP. Dx and causes.

Hypotonic Hypervolemic hyponatremia -Renal failure -Cirrhosis -CHF -Nephrotic syndrome

Low sodium (Na < 135) and low serum osmolality (<275) and dry mucosa and increased skin turgor. Dx and causes.

Hypotonic Hypovolemic hyponatremia -Diarrhea -Vomiting -Sweating -Burns -Diuretics -Aldosterone deficiency -Nephropathy

Three types of hypernatremia are hypovolemic, isovolemic, or hypervolemic. Give examples of etiologies of each type.

Hypovolemic hypernatremia - lack of access to water, excessive sweating Isovolemic hypernatremia - renal water losses - diabetes insipidis, fever, burns Hypervolemic hypernatremia - seawater ingestion, cushings, exogenous steroids

What is the major cause of high altitude syndromes?

Hypoxia

Patient presents with fatigue, jaundice, pruritus, yellow plaques, osteoarthritis, and portal htn. What would you like to order? What is the likely diagnosis?

I want LFTs, ALKphos, +AMA, Liver biopsy confirms diagnosis Likely biliary cirrhosis

What are the axis of the DSM-IV?

I- all psychological categories except retardation II-Personality disorder and retardation III-General and acute medical conditions IV-Psychosocial/environemental factors

A 27-year-old African American female presents to the emergency department with low blood pressure of 100/40, palpitations, and shortness of breath. She is currently under treatment for Wolff-Parkinson-White syndrome and has been taking procainamide for the last two years. An electrocardiogram is obtained on the monitor and reveals the rhythm strip shown. What is the treatment of choice for this patient? EKG shows tosades de pointe A Intravenous calcium B Intravenous magnesium C Oral potassium D Subcutaneous epinephrine E Metoprolol

IV Mg B The rhythm strip reveals ventricular tachycardia in the form of torsades de pointes. In this case, the primary medical intervention is to administer magnesium sulfate to counter the irregular activity. Antiarrhythmics, antidepressants, and some antibiotics can be responsible for this arrhythmia. In addition to the magnesium, administration of beta-blockers can also be helpful.

What is the gold standard imaging for diagnosing suspected kidney injury after trauma?

IV contrast enhanced abdominal/pelvic CT

How do we treat arterial occlusion of a peripheral limb?

IV heparin or embolectomy

A 55-year-old woman with a history of mitral valve replacement and mitral stenosis (secondary to rheumatic heart disease) presents to the emergency department with increasing dyspnea while walking up one flight of stairs. She denies chest pain and discomfort, but states that for the past few weeks she has noticed palpitations. She also admits to lower extremity edema, which is new within the last week. On EKG, she demonstrates atrial flutter with 2:1 AV block. Her INRs have been therapeutic for the past 4 weeks. Which of the following is the most appropriate next step in treating this patient? A IV quinidine B IV ibutilide C IV vasotec D IV amiodarone E IV dopamine

IV ibutilide Choice B, IV ibutilide, has been found to be most effective in converting atrial flutter to sinus rhythm out of all the choices listed. Choice A is contraindicated, as the atrial conduction may decrease to the point that 1:1 atrial to ventricular conduction can occur with the administration of class I antiarrhythmics. The ventricular rate can then increase to rates greater than 200 bpm, and hemodynamic collapse may occur. Choice C is useful for blood pressure control, but not for heart rate control. Choice D is useful for chronic atrial flutter heart rate management, or for helping to maintain sinus rhythm after cardioversion has occurred. Choice E is useful for pressor support, and not for heart rate control or conversion to normal sinus rhythm.

A 55-year-old woman with a history of hypertension and 2 vessel CABG presents to the emergency department with increasing dyspnea while walking up one flight of stairs. She denies chest pain and discomfort, but states that for the last 24 hours she has also noticed palpitations. On physical examination, her vital signs are stable. On EKG, she demonstrates atrial flutter with 2:1 AV block. Her echocardiogram demonstrates normal LV systolic function and normal valvular function. Which of the following is the most appropriate therapy for this patient? A IV ibutilide after 4 weeks of anticoagulation with warfarin B IV ibutilide alone C IV quinidine after 4 weeks of anticoagulation with warfarin D IV quinidine alone E IV dopamine

IV ibutilide alone Choice B, IV ibutilide, is the most appropriate choice for this patient. Therapy for patients with atrial flutter and atrial fibrillation is the same in regards to anticoagulation; therefore, in a patient with a CHADS2 score of 1 and with symptoms of less than 48 hours duration, cardioversion to normal sinus rhythm, whether chemically or electrically, is recommended. Out of all the choices listed, IV ibutilide has been found to be most effective in converting atrial flutter to sinus rhythm. Choices C and D are contraindicated, regardless of the type of anticoagulation paired with it, as quinidine is a class I antiarrhythmic. The atrial conduction may decrease to the point that 1:1 atrial to ventricular conduction can occur with the administration of class I antiarrhythmics. The ventricular rate can then increase to rates greater than 200 bpm, and hemodynamic collapse may occur. Choice E is useful for pressor support, which is not indicated in this patient who is quite stable.

A 65-year-old recent alcoholic comes to the emergency department with recent onset of dyspnea with exertion, 3 pillow orthopnea, lower extremity edema, and palpitations, in which he describes his heart as racing. Which of the following is the most appropriate treatment for his high-output congestive heart failure? A IV dextrose alone B IV thiamine C IV enalapril D IV dopamine E IV diltiazem

IV thiamine Choice B is the most appropriate treatment, as the patient is demonstrating high output congestive heart failure secondary to beriberi, or thiamine deficiency. In 50% of patients, IV thiamine administration, along with other vitamins and glucose, will resolve the patient's symptoms. Choice A, IV dextrose alone in patients with very low thiamine stores, can worsen signs and symptoms of heart failure. Choice C, IV enalapril, is appropriate therapy for patients in need of better blood pressure control, and as an ACE inhibitor, in patients with left ventricular systolic dysfunction, which is not the cause of this patient's heart failure. Choice D, IV dopamine, is useful in patients in need of pressor support, but will not help treat high-output heart failure secondary to thiamine deficiency. Choice E, IV diltiazem, is useful for heart rate control in patients with atrial fibrillation with a rapid ventricular rate.

If a patient with a DVT has active internal bleeding, uncontrolled HTN, CNS tumor, recent trauma or surgery, or recurrent DVT despite anticoagulation, what alternative treatment should be considered?

IVC filter

When would you not perform any cervical spine imaging in a patient who had spinal trauma?

If all of the following: -No cervical tenderness -Normal alertness and consciousness -No intoxication -No focal neuro deficit -No painful injury

What is the treatment for a tension pneumothorax?

Immediate needle decompression at 2nd intercostal space at midclavicular line

____or "honey colored crust" are contagious, superficial skin infections caused by Staph Aureus. Tx: Mupirocin ointment or Bactroban cream. Severe infection, use dicloxacillin. Keep clean.

Impetigo

What is Kussmauls sign? Which of the following conditions would cause a positive Kussmaul's sign on physical examination

Increase central venous pressure in response to inspiration- as opposed to decreased central venous pressure normally Pericarditis or rightsided heart failure

What are causes of metabolic acidosis with increased anion gap? (3) What is the most common among nondiabetic patients?

Increased anion gap with metabolic acidosis is caused by *lactic acidosis, ketoacidosis, and renal failure.* Lactic acidosis

Fever, chills, weakness, dyspnea, heart murmurs, petichiae, splinter hemorrhages, osler nodes (tender nodules on finger and toe pads), janeway lesions (plaques on palms and soles). Dx and tx.

Infective endocarditis -Get 3 separate cultures over an hour -Ceftriaxone + Gentamicin (if uncomplicated history) -Nafcillin + Gentamicin + Vancomycin (if IV drug user) -Rifampin + Gentamicin + Vancomycin (if prosthetic heart valve)

ST Elevations in II, III, aVF

Inferior MI; right coronary artery

Aspiration of joint reveals: yellow, cloudy fluid with 200-50,000 WBCs and > 50% PMNs. Dx.

Inflammatory fluid Could be due to: -Gout -Pseudogout -RA -Lyme disease -SLE

Abrupt onset of fever, chills, headache, mylagia, malaise, dry cough, rhinorrhea, sore throat, bilateral tender cervical lymph nodes. Dx and tx.

Influenza -Oseltamivir

Influenza - caused by influenza A or B. Antivirals can shorten the course. Rimantadine and Amantadine can be used to shorten course of ______. Zanamivir and Oseltamivir can shorten the course of _____.

Influenza A; Influenza A or B.

Flu-like symptoms progressing quickly to mediastinal and hilar edema and respiratory failure. Dx and tx.

Inhalational anthrax -Cipro + Clindamycin -Admit

What type of drug is Qvar (Beclamethasone)?

Inhaled corticosteroid

A 3 year-old boy is brought to the emergency department due to acute onset of cough and wheezing. Physical exam reveals focal wheezing in the right lower lobe. Which of the following should be ordered to confirm the suspected diagnosis? A Arterial blood gas B Inspiratory and forced expiratory chest x-rays C PA and lateral chest x-ray D Peak expiratory flow rate E Spirometry

Inspiratory and forced expiratory chest x-rays The patient most likely has aspirated a foreign body. This is best evaluated through the demonstration of inspiratory localized hyperinflation and expiratory mediastinal shift (B) on chest x-ray. ABG (A) results will vary depending on the severity of airway obstruction. PA and lateral chest x-rays (C) are typically normal. PEFR (D) and Spirometry (E) are not typically able to accurately assess this localized airway obstruction.

A 43-year-old male presents to the Emergency Department complaining of right eye pain after treating his yard with fertilizer and lime. He attempted to flush his eye at home without relief of pain. Which of the following is the most appropriate initial step in managing this patient's symptoms? A Double evert his eyelids to look for remaining foreign bodies B Fluorescein stain his eye C Instill proparacaine 0.5% ophthalmic solution D Irrigate his eye until the pH is between 6.8 and 7.4 E Refer to ophthalomogist

Instill proparacaine 0.5% ophthalmic solution The patient requires all of the above steps and should be given pain relief (C) prior to thoroughly flushing the eye (D), removing foreign bodies (A), assessing for corneal injuries (B), and referring to ophthalmology (E).

A soft tissue neck x-ray of a patient who complains of a progressively worsening sore throat reveals this lateral film (see image). Based on these findings, what is the initial treatment of choice for this patient? A Endotracheal intubation B Intravenous steroids C Ribovirin injection D Incision and drainage E Cricoidotomy

Intravenous steroids This case of acute epiglottitis is treated with immediate intravenous steroids. Provided that the patient is able to maintain the airway and also keep oxygen saturation rates above 92%, the patient can improve with steroids and supportive care. Antiviral medications have little effect on the overall illness.

____occurs in infants and children 2month - 6 years. Currant jelly stools, inconsolable crying, drawing up legs. What can be used both as a diagnostic and therapeutic maneuver?

Intussusception; air enemas

Hypothermia: Pathogneumonic on EKG

J wave of Osborn Especially in Lead II

More common fractures ____is a transverse fracture of diaphyseal region of base of fifth metatarsal. ____is a fracture/dislocation of tarsometatarsal joint. ____is a stress fracture of the metatarsal. ___is fracture of anterolateral aspect of the distal tibia in adolescents before complete closure of the epiphysis.

Jones, Lisfranc, March, Tillaux

What is the definition of hypokalemia?

K < 3.5

What is the definition of hyperkalemia?

K > 5.5

A 3 year-old boy is seen in the office with a 5-day history of fever, erythema, edema of the hands and feet, a generalized rash over the body, bilateral conjunctival injections, fissuring and erythema of the lips, and cervical adenopathy. Antistreptolysin A (ASO) titer and throat culture are negative. The most serious systemic complication associated with this disorder is

Kawasacki syndrome- high fever, rash, and cracking skin- can cause aneurysms of the coronary artery

____sign refers to pain in the neck or back that occurs when a pt with meningitis attempts to extend the leg at the knee while the thigh is held in 90 degrees of flexion. ____sign refers to spontaneous flexion of the hips during attempted passive flexion of the hips during attempted passion flexion of the neck.

Kernig; Brudzinski

Nearly all cases of epistaxis originate anteriorly within the mucosa of the nasal septum in a region known as ____. Why is posterior epistaxis harder to manage?

Kiesselbach plexus (anterior) vs. Woodruff plexus (posterior); posterior is harder to manage because application of direct pressure does not compress area

Which bacteria in Pneumona is common in diabetes, alcoholism, and nosocomial infections?

Klebsiella

A 14-year-old boy presents to the emergency department with his parents. He has a history of type 1 diabetes, and has had bronchitis for the last few days. He is now presenting with difficulty breathing, worsening fatigue, polydipsia, and polyuria. His last fingerstick glucose at home this morning was 350 mg/dL. Which of the following patterns of breathing are characteristic of this complication of diabetes? A Cheyne stokes respiration B Bradypnea C Biot breathing D Kussmaul breathing

Kussmaul breathing The correct choice is D, Kussmaul breathing, which is deep regular breathing or hyperpnea. It can be seen as a compensatory action of metabolic acidosis and hypoxia. Choice A, Cheyne-Stokes respiration, is a waxing and waning pattern of rate and volume that includes periods of apnea. This can be seen in patients at high altitudes, and with severe left sided heart failure or neurologic disease. Choice B, bradypnea, is noted with a slower than usual respiratory rate and can be seen with use of CNS depressant drugs, uremia, or structural intracranial lesion. Choice C, Biot breathing, is an uncommon variant of Cheyne-Stokes respiration, with periods of apnea alternating with a series of equal breaths that end abruptly. It can be seen in patients with meningitis. Choice E, painful respiration, is relatively normal in pattern, but interrupted by pain during breathing from such disorders as pleurisy, fractured ribs, or subphrenic inflammation.

Cervical and Lumbar Radiculopathies L4 - motor weakness? decreased reflex? decreased sensation?

L4 motor - anterior tibialis reflex - patellar tendon sensation - shin

Cervical and Lumbar Radiculopathies L5 - motor weakness? decreased reflex? decreased sensation?

L5 motor - extensor hallicus longus reflex - none sensation - top of foot, first web space

What is the most common cause of hyperkalemia?

Lab error (pseudohyperkalemia) MC cause of true hyperkalemia = Renal failure with oliguria

What are some of our pharm options for reducing BP in emergency/urgency?

Labetalol Soidum Nitro Esmolol Nicardipine- good for enceph/stroke Hydralazine- good for pregnant

Which of the following is the drug of choice for acute hypertensive encephalopathy? A Labetolol B Clonidine C Furosemide D Nifedipine E Nitroglycerin

Labetolol Neurologic emergencies associated with elevated blood pressure must be throurougly evaluated to determine the diagnosis and appropriate treatment plan. In the case of hypertensive encephalopathy, immediate attention must be focused on blood pressure reduction. Multiple agents are known to decrease blood pressure, but selection must also focus on how rapidly each agent works, how titratable the agent is, and any potential sequelae from using a particular agent. Sodium nitroprusside was classically the agent of choice for rapid blood pressure management, but it has fallen out of favor due to its monitoring requirements and rate of toxicity. Labetolol, a beta-blocker, is recommended for acute management, except in the case of cocaine intoxication. It has a rapid onset of action, can be titrated, and is given IV. Use of labetolol should be avoided in patients with known asthma, COPD, congestive heart failure, bradycardia, and second or third degree heart block. Additional agents appropriate for hypertensive encephalopathy include enalaprilat, esmolol, fenoldopam, hydralazine, and nicardipine, with each being considered carefully (based on patient condition and other factors). Agents with known CNS adverse effects, such as clonidine, should be avoided. Use of clonidine must also be monitored due to potential rebound hypertension. Nifedipine use is discouraged in hypertensive emergencies. Nitroglycerin should not be used for hypertensive encephalopathy because it increases intracranial pressure (additional information is available in Table 61-4).

____is acute unilateral infection or inflammation of the vestibular system - typically due to a recent viral infection. CP: rotational vertigo, nystagmus, n/v. What kind of nystagmus? Tx?

Labyrinthitis; horizontal - rotary away from affected side; diazepam, meclizine, dimenhydrinate

What is the most sensitive test for ACL injuries?

Lachman test

A patient presents with splenomegaly, fatigue, and LAD. Pt reveals she has had a sore throat for 2 weeks. What might we see on a blood smear?

Large lymphocytes

How do you diagnose MCL and LCL tears?

Laxity > 1 cm without a firm end point (compared with other knee) Valgus laxity = medial tear Varus laxity = lateral tear

Fresh water exposure, high fever, severe headache, mylagia, hepatitis, conjunctivits without purulent discharge. Dx and tx.

Leptospirosis -Amoxicillin

Treatment for alcohol withdrawal

Librium and Ativan

Red dots on waist, shoulders, axillae that progress to papules and wheals. Intense itching leads to linear excoriations. Small white spheres attached to hair. Dx and tx.

Lice -Permethrin -Pyrethrin + Pperonyl butoxide (if in hair) -Hot water washing of clothes, bedding, etc.

Purple patches that are polygonal and pruritic. Wickham striae (lacy reticulated pattern or white lines on papule). Dx.

Lichen planus

DM patient with > 2 cm deep ulcer with fever, ischemic changes, and lymphangitis. Dx and tx.

Limb/Life-Threatening Foot Ulcer -Admit -Consult surgery -IV imipenem-cilastin (if life-threatening) -IV ampicillin-sulbactam (if limb-threatening)

Most common complication of Amebiasis?

Liver abscess

Stung by insect followed by pain, erythema, edema, and pruritus at the sting site. Dx and tx.

Local reaction to Hymenoptera -Antihistamines -Analgesics -Remove stinger and clean wound with soap/water -Ice and elevation (to reduce swelling) -Prescribe EPI Pen

A 7-year-old is diagnosed with an acute case of hematogenous osteomyelitis accompanied with fever and leukocytosis. Based on your knowledge of the disease, which bone is most likely to present with the infection? A Feet B Hands C Long bones D Pelvis E Vertebrae

Long bones Fortunately, hematogenous osteomyelitis is not common in children, but when it does occur it primarily is found in the long bones. The femur, tibia and humerus are the most typical locations for osteomyelitis in children. The highly vascular metaphysis of long bones contribute to the potential for hematogenous spread of the implicated pathogen. Osteomyelitis can occur at any of the locations mentioned in the answer choices given, but at a significantly lower rate than in the long bones. The rate of occurrence at several selected locations is given below: Feet - 9% Femur 25% Hands - 6% Humerus - 13% Pelvis - 8% Radius/ulna - 6% Tibia/fibula - 28% Vertebrae - 2%

Most common cause of hypokalemia?

Loop diuretics

A 24-year-old male is brought to the emergency department by his girlfriend. She states that he began having a seizure in the car approximately seven minutes ago. She is not sure of his medications, but states he has a known seizure history and has seizures a few times a year. The patient is currently actively seizing. Which of the following is the first-line agent to give this patient? A Carbamazepine B Gabapentin C Levetiracetam D Lorazepam E Phenytoin

Lorazepam D This patient has a known history of seizures, with current ongoing seizure activity and the concern of status epilepticus, a true emergency. Prolonged seizure activity is associated with hyperthermia, metabolic disturbances, cardiopulmonary dysfunction, and irreversible damage. Lorazepam, a benzodiazepine, increases the activity of gamma-aminobutyric acid (GABA) in the brain, thereby calming the excessive electrical nerve activity related to the seizure and slowing the central nervous system. It is the preferred first line agent for temporary control of seizure activity due to the duration of action of approximately 12 to 24 hours. This allows additional therapeutic agents to be administered while gaining control of the seizure activity. The other agents are antiepileptic medications, which are used for long-term seizure control. They are differentiated by efficacy, convenience, side effects, and drug-drug interactions.

Which physical complaint is the leading cause of lost work time and disability for patients under the age of 45? A Ankle pain B Hip pain C Knee pain D Low back pain E Shoulder pain

Low back pain D Low back pain is the most common causes of lost time from work and disability. Factors that can lead to back problems include repeated or heavy lifting and twisting or use of vibrating equipment along with poor fitness levels, smoking, poor job satisfaction and other psychosocial factors. Fortunately, 80% of patients experience significant recovery within one month. All of the other types of pain can occur based on multiple factors, but none of them occur with a frequency that rivals low back pain

_____often originates at a site of dental infection and is a cellulitis of the floor of the mouth and neck originating in the submandibular space.

Ludwig's angina

"Spilled teacup sign" on lateral x-ray of wrist. Dx and tx.

Lunate dislocation Consult ortho for reduction

Most common vector-borne zoonotic infection in the US?

Lyme disease

Tick bite, erythematous plaque with central clearing (erythema migrans), arthralgia, fatigue. Dx and tx.

Lyme disease (spirochete Borrelia burgdorferi) -Doxycycline

With knee ligamentous injuries -- which ligament is not usually treated with surgery?

MCL - medial collateral ligament

What labs must we monitor to avoid digoxin toxicity in a HF patient?

MG, K, and high Ca

Most common cause of cardiogenic shock?

MI

Name three effects of malignant hypertension for each. Cardiac Neuro Others

MI, LV dysfunction, pulmonary edema Encephalopathy, CVA, hemorrhage Renal failure, retinopathy, eclampsia

What is the standard treatment for a MI? What is the door to balloon time? What is the door to needle time?

MONA- Morphine, O2, Nitro, Aspirin 90 minutes 30 minutes

What are the pre hospital treatments for ACS?

MONA; morphine, oxygen, nitroglycerin (0.4mg SL x3 prn), aspirin (325mg)

What is the definitive test to order when a patient has back pain and neurologic deficits?

MRI

A 62-year-old man is brought to the emergency department after being found unresponsive in his car. On physical examination, his pupils are noted to be 7 mm on the right and 3 mm on the left. Which of the following diagnostic tests is most likely to identify the cause of the patient's signs and symptoms? A CBC with differential B serum electrolytes C MRI with contrast D liver function tests E skull X-rays

MRI with contrast C The patient's unilateral symptoms are best explained by a local anatomical cause (e.g., tumor) that would be detected with an imaging study (MRI). An MRI is preferred over skull X-rays to assess directly for intracranial pathology. CNS abnormalities arising from systemic causes are more likely to be symmetric.

"Spider bite" that is warm, red, tender, and purulent. Dx and tx.

MRSA -I&D -Clindamycin or Bactrim if immunocompromised or large abscess

Duke Criteria for dx of infective endocarditis Dx with 2 major or 1 major and 3 minor

Major a. positive blood cultures b. endocardial involvelment on echo Minor a. predisposing condition: cardiac or IV drug use b. fever c. vascular phenomenon d. immunologic phenomenon

Recent travel with cycles of high fever and chills, cough, myalgia, diaphoresis, malaise, N/V, diarrhea. Splenomegaly, Normocytic anemia, thrombocytopenia. Dx and tx.

Malaria (plasmodisum) -Giemsa stain -Quinine sulfate + Doxycycline (assuming resistance) -Chloroquine + Primaquine phosphate (if know it is not resistant to chloroquine)

____hypertension is potentially life threatening - HTN plus rentinopathy, cardiovascular/renal compromise, or encephalopathy.

Malignant

Complete rupture of the extensor tendon at the level of the distal phalanx. DIP joint flexion of finger. Unable to actively extend DIP joint. Dx and tx.

Mallet finger Splint in hyperextension

What congenital disease is known to put a person at increased risk for aortic dissection?

Marfans syndrome or erhlos-danlos

____is a regional infection of the breast typically seen in lactating women; caused by patient's skin flora or oral flora of infant. Tx: dicloxacillin; complications include development of _____.

Mastitis; breast abscess which would be I&D; usually caused by Staph Aureus

______is a rare complication of otitis media. CP with pain, swelling, tenderness, and redness behind the ear in the area of the mastoid bone. Treat the same as otitis media but what is the difference?

Mastoiditis; treat for 3-4 weeks

What drugs are contraindicated in CHF?

Metformin, glitzones, NSAIDS, antiarrhythmics

Scuba diver with hearing loss, tinnitus, vertigo, positive fistula test (eyes deviate to contralateral side of TM insufflation). Dx and tx.

Middle Ear Squeeze Barotrauma -Decongestant -Analgesics -Bed rest with head upright

What is the most common disorder in scuba divers?

Middle Ear Squeeze Barotrauma (during descent)

What are the values for mild, moderate, and severe levels of the Glasgow Coma Scale?

Mild = 14 or higher Moderate = 9-13 Severe = 8 or lower

______is a pansystolic, blowing in nature, high pitch, musical sound. Radiates to left axilla.

Mitral regurgitation

______presents with an opening snap in early diastole. Soft, low-pitched, diastolic rumble heard best at the apex in the left decubitus position, palpable right ventricular heave.

Mitral stenosis

Most common valve affected by infective endocarditis?

Mitral valve

A patient presents with fatigue, anxiety, and palpitations. PE reveals a midsystolic click. Possible diagnosis?

Mitral valve prolapse

______presents with a mid-systolic click heard best at apex.

Mitral valve prolapse

Aspirin (Salicylate) OD: -Net effect?

Mixed Respiratory Alkalosis + Metabolic Acidosis

Proximal ulna fracture with radial head dislocation at elbow. Dx and tx.

Monteggia fracture -Refer for ORIF (open reduction and internal fixation)

A fracture of the proximal ulna with anterior dislocation of the radial head is known as...? Fracture along the length of the radius with injury at the distal radialulnar joint is known as...?

Monteggia fracture Galeazzi fracture

More common fractures ____is an ulna shaft fx with proximal radius dislocation. ____is a radial fracture w a distal ulna dislocation. MUGR ____is a isolated ulna fracture. ____is fx of proximal third of fibular associated w rupture of distal tibiofibular syndesmosis.

Monteggia, Galeazzi, Nightstick, Maisonneuve

How do you test motor and sensory function of the ulnar nerve?

Motor = Abduct/Spread fingers against resistance Sensory = little finger

How do you test motor and sensory function of the radial nerve?

Motor = Extension of wrist and fingers against resistance Sensory = Dorsum of thumb; Index web space

How do you test motor and sensory function of the median nerve?

Motor = Flexing thumb distal phalanx against resistance (or make "ok" sign with thumb and pinky) Sensory = tip of index finger

What types of connective tissue are injured in a strain? A Bones and muscles B Fascia and joint capsules C Ligaments and joint capsules D Muscles and tendons E Tendons and bones

Muscles and tendons A strain involves injury to the muscles and tendons that are responsible for active movement of various body parts. Fascia is a part of the muscle-tendon unit, so injury to fascia would be considered a strain as well. Injury to ligaments and joint capsules would be considered a sprain and damage to bone would be classified as a fracture.

A 15 year-old male was seen last week with complaints of sore throat, headache, and mild cough. A diagnosis of URI was made and supportive treatment was initiated. He returns today with complaints of worsening cough and increasing fatigue. At this time, chest x-ray reveals bilateral hilar infiltrates. A WBC count is normal and a cold hemagglutinin titer is elevated. The most likely diagnosis is

Mycoplasma pneumonia- interstitial hilar infiltrates, elevated cold hemagglutinin titer, and insidious onset of symptoms

Cardiac Markers: _____is detectable within 1-2 hours after acute MI. Duration <1 day. Low specificity.

Myoglobin

Elderly woman with a recent infection has hypothermia, bradycardia, hypotension, altered mental status, respiratory depression, constipation, edema, rough dry skin, enlarged tongue, seizures, megacolon. Dx and tx.

Myxedema Coma (Hypothyroidism crisis) -Airway stabilization -Fluids (for hypotension) -Rewarming (for hypothermia) -Levothyroxine -Admit

Patients with long standing hypothyroidism may develop this. Myxedema coma is a syndrome of hypothermia, AMS, respiratory insufficiency, and myxedema. ____is a nonpitting, dry, waxy swelling of the skin caused by deposition of mucopolysaccharides in the dermis. What is the cornerstone of treatment?

Myxedema; IV levothyroxine, supportive care, and hydrocortisone to avoid adrenal insufficiency

Pt with hf is on digoxin. What SE can we expect?

N/V, anorexia, ectopic beats

Describe treatment and PE findings for *acute* pericarditis.

NSAIDS- typically self resolving better leaning forward, friction rub

What is the definition of hyponatremia?

Na < 135

What is the definition of hypernatremia?

Na > 150

Antidote → Opiods

Naloxone (Narcan) *Reverses effects

___is used for opiate and heroin overdose. ___is used for acute benzodiazepine overdose. ___is used for tricyclic antidepressant overdose.

Naloxone; Flumazenil; Sodium Bicarbonate

Most common form of infective endocarditis?

Native valve endocarditis

Abdominal pain, severe anemia, red burrows underneath skin. Dx and tx.

Necator americanus hookworm -Albendazole

Localized pain out of proportion, heaviness in affected extremity, brown skin discoloration, malodorous discharge, crepitance, low grade fever, tachycardia. Dx and tx.

Necrotizing Fasciitis -IV crystalloids -IV vancomycin + meropenem -Surgical consult for debridement, fasciotomy, amputation

An 18-year-old woman is transferred to your emergency department from a local college infirmary. She presented yesterday with a complaint of headache but became confused and is now febrile. You notice a petechial rash on physical examination and her cerebrospinal fluid comes back with increased WBCs, increased protein, and decreased glucose. What is the most likely organism responsible for her meningitis? A Haemophilus influenzae B cytomegalovirus C Neisseria meningitidis D Mycobacterium tuberculosis E coxsackievirus B

Neisseria meningitis C Neisseria meningitidis and Streptococcus pneumoniae are the most common etiologic agents for bacterial meningitis in this patient's age group. So much so that many colleges and universities require a vaccine for students who live in dormitories. Her fever and the cerebrospinal fluid values are consistent with a bacterial and not a viral infectious source for the meningeal irritation.

A 19 year-old-male is brought to the emergency department due to psychosis. During the evaluation, he is noted to appear unkempt and has reduced motor activity. His affect is flattened, and he is using made-up words and phrases during speech. This patient is exhibiting what type of verbal utterance? A Echolalia B Hallucination C Neologism D Catatonia E Verbigeration

Neologism C The use of made-up words or phrases is termed neologism. Echolalia is a repetition of words spoken by others. Hallucinations are perceptual distortions, and may be auditory or visual. Catatonia describes a state in which a person is withdrawn and shows minimal bodily movement, or one in which there is severe excitement and the person shows purposeless and stereotyped movements. Verbigeration is the repetition of senseless phrases or words.

A 56-year-old male, with history of hyperlipidemia and non-insulin-dependent diabetes mellitus (NIDDM) presents to the emergency department with a history of increasing peripheral edema over the past week. On examination he is noted to have periorbital, scrotal, and +2 pretibial edema. His lungs are CTAB. He denies any chest pain or shortness of breath. Urine dipstick reveals 4+ protein. Urine microscopic reveals Maltese crosses consistent with lipiduria. Labs include a decreased serum albumin of 2 g/dl, decreased total protein of 5.5 g/dl, and normal glomerular filtration rate (GFR). What is the most likely diagnosis? A pyelonephritis B congestive heart failure (CHF) C nephrotic syndrome D prostatitis

Nephrotic syndrome C The correct answer is (C). This patient has typical symptoms of nephrotic syndrome, which includes significant proteinuria, hypoalbuminemia, and typical presentation of edema. He also has a history of hyperlipidemia and laboratory findings of lipiduria, which is also common in nephrotic syndrome. Furthermore, his history of diabetes mellitus is also a potential cause of nephrotic syndrome. Pyelonephritis and prostatitis would present with urine WBCs and is not consistent with the laboratory findings or edema. CHF would more likely present with dyspnea, rales on exam, and peripheral edema but would unlikely involve the periorbital area. DVT would likely present with unilateral swelling of the LE, and discomfort and is not consistent with the laboratory findings above.

Hypotension, warm dry skin, bradycardia. Dx and tx.

Neurogenic shock -Keep pt supine and reduce movement -Oxygen -Volume replacement -High dose dopamine

Bradycardia and hypotension following trauma to the spine. Dx and tx.

Neurogenic shock -Oxygen -IV fluids -Vasopressors if needed -Pacemaker if severe bradycardia

What meds should a patient go home with after ACS?

Nitroglycerin BB ACEi ASA/Clopidogrel anticoagulant (up to 8days for LMWH) aldosterone agonist statin LIFESTYLE CHANGES

Most common neoplasm in HIV patients?

Non-hodgkin lymphoma

Aspiration of joint reveals: yellow, transparent fluid with 200-2000 WBCs and < 25% PMNs. Dx.

Non-inflammatory fluid Could be due to: -Osteoarthritis -Trauma -Rheumatic fever

DM patient with < 2 cm superficial foot ulcer with no fever or ischemic changes. Dx and tx.

Nonlimb-Threatening Foot Ulcer -Debride necrotic tissue and callus -Cephalexin or Augmentin po -Outpatient follow-up in 24-72 hours

What is the only fluid replacement that can be used in the same line as blood components?

Normal Saline

Renal tubular acidosis is what type of acidosis?

Normal anion gap metabolic acidosis

Aspiration of joint reveals: clear, transparent fluid with <200 WBCs and < 25% PMNs. Dx.

Normal joint fluid

Most common pathogen for foodborne disease?

Norwalk-type Virus

What are the noninvasive tx for CHF?

O2, positive pressure ventilation, Na restriction

Impaired filling of ventricles severe enough to cause a fall in cardiac output is...

Obstructive shock

What are the Ottawa ankle rules?

Obtain x-rays (mortus view) if pain at malleolus or midfoot plus one of the following: -Tenderness at distal 6 cm tibia or tip of medial malleolus -Tenderness at distal 6 cm fibula or tip of lateral malleolus -Tenderness at base of 5th metatarsal -Tenderness at navicular bone -Inability to take 4 steps immediately and in ED

What medication is first line therapy for schizophrenia?

Olanzapine -Clozapine, chlorpromazine, and haloperidol are all older drugs with higher side effect profiles

A 56-year-old right hand dominant male presents with swelling to the right elbow. He explains to you that he has had this type of swelling before and was diagnosed with bursitis. Based on this description, where would the most likely site for the elbow bursitis be located? A Capitellum B Lateral epicondyle C Medial epicondyle D Olecranon E Radial head

Olecranon D The olecranon bursa is very vulnerable to injury and chronic inflammation due to its superficial location on the extensor side of the elbow. Acute falls, chronic pressure, and other inflammatory processes such as rheumatoid arthritis or gout may contribute to olecranon bursitis. The medial and lateral epicondyles are known to be associated with chronic tendonopathies. The radial head is a common location for subluxation or fracture, while the capitellum at the distal end of the humerus is sometimes associated with fractures and articular cartilage damage.

_______refers to inflammation at any point along the optic nerve and presents with acute vision loss, with a particular reduction in color vision. Optic disc appear swollen. Tx: steroids

Optic Neuritis

___is inflammation of the testes often from Coxsackie B or mumps virus. Fever, chills, nausea, lower abdominal pain. Tx: supportive

Orchiitis

The most common pathogen in ____is Pseudomonas Aeroginosa but can also be caused by Staph aureus, GAS, and aspergillus. Tx usually consists of a mixture of polymyxin, neomycin, and hydrocortisone.

Otitis Externa

______cysts only cause pain when they leak contents causing tissue irritation or mechanical pressure on adjacent organs. What is the diagnostic imaging modality of choice? What patient requires emergent gynecological surgery?

Ovarian; pelvic/transvaginal ultrasound; patients with hemoperitonium and/or hypotension

Causes of hypercalcemia?

PAM P SCHMIDT -Parathyroid hormone excess -Addison disease -Multiplemyeloma -Paget disease -Sarcoidosis -Cancer -Hyperthyroidism -Milk-alkali syndrome -Immobilization -D vitamin excess -Thiazide diuretics

What is the testing modality of choice for HSV meningoencephalitis?

PCR testing of the CSF

A 66-year-old female with a history of nephrotic syndrome presents to the emergency department complaining of a non-productive cough and dyspnea on exertion following a recent vacation to Orlando. She is currently taking prednisone. What diagnosis is highly suspected in this patient due to her history of nephrotic syndrome? A pneumonia B pulmonary embolism C chronic obstructive pulmonary disease (COPD) exacerbation D Cushing's syndrome E asthma exacerbation

PE The correct answer is (B). Patient's with nephrotic syndrome commonly have a hypercoagulable state and are at risk for deep venous thrombosis (DVT) with resultant PE. Patients on chronic prednisone may have a risk of developing Cushing's syndrome, but this is not consistent with the patient's history. Pneumonia is possible due to chronic prednisone use but not directly caused by her history of nephrotic syndrome. COPD and asthma are not linked to nephrotic syndrome.

What PE and EKG changes are seen with dilated cardiomyopathy?

PE: S3, JVD, crackles - possible mitral regurg EKG: nonspecific ST and T wave changes, LBBB

Patients with life threatening dysarhthmias should be treated how? Syncope caused by orthostatics? Vasovagal?

Pacemaker Hydrate Educate to recognize prodrome

What is the most common complaint in sickle cell patients?

Pain

When would we do surgery for someone with arterial insufficiency?

Pain at rest, ischemic ulcers, severe symptoms refractory to tx

____is optic disc swelling caused by increased intracranial pressure.

Papilledema

What is the most, and second most, reliable ways for ensuring proper tube placement?

Passage through the vocal cords End CO2 device monitoring

Pain and tenderness over patella with joint effusion. Dx and tx.

Patella fracture -Knee immobilization in extension -Consult ortho

Describe an indirect hernia.

Patent processus vaginalis and hernia contents

Pain and deformity of the knee after a twisting injury while playing a sport. Dx and tx.

Pattela dislocation -Reduce with hyperextension of knee and flexing hip -Immoblize in extension post-reduction -Ortho follow up

What three medications are first line for hepatitis B?

Pegy, ente, teno.

Pain, crepitus, instability of pelvis, and hematoma over inguinal ligament after a high impact trauma. Dx and tx.

Pelvic fracture -Look for sources of hemorrhage -DRE (look for tone, prostate height, bleeding) -ORIF (open reduction internal fixation)

____is a serious complication of STIs because of increased risk of infertility and ectopic pregnancy. Lower abdominal tenderness, Chandelier's sign, and purulent cervical discharge. ABX: broad spectrum cephalosporins, clinda/gent if allergic

Pelvic inflammatory disease (PID)

Clear, tense vesicles and bullae on head, trunk and mucous membranes. Bullae rupture in 2-3 days producing painful denuded areas. Dx and tx.

Pemphigus Vulgaris -Admit -Fluids -Corticosteroids and immunosuppressive therapy -Dermatology consult

Small bowel and colon injuries are most commonly caused by what type of trauma?

Penetrating trauma

Chest pain, fever, and friction rub 2-4 weeks after cardiac trauma. Dx and tx.

Pericardial Inflammation Syndrome -NSAIDs (Indomethacin)

What are the most common symptoms of thrombocytopenia or dysfunction platelets?

Petechiae of lower extremities

Bit by a snake. Fang marks in skin. Pain, erythema, ecchymosis, and edema extending from bite. N/V, perioral parasthesia, lethargy. Elevated INR and PTT. Dx and tx.

Pit Viper bite -Consult poison control -Constriction band placed proximal to bite -Antivenom tx with FabAV -Mannitol (if compartment syndrome) -Prednisone (if serum sickness develops in response to FabAV)

Herald patch for 1-2 weeks before patches erupting in christmas tree pattern following skin lines. Dx.

Pityriasis rosea

Spaghetti and meatballs appearance on KOH. Dx.

Pityriasis versicolor

Flea bites, fever, painful and suppurative bubos (enlarged lymph nodes) in the groin. Dx and tx.

Plague (Yersinia pestis) -Gentamicin

What are the most reliable measures of dehydration?

Plasma and urine osmolarity

________can lead to cardiac tamponade if it is large. Friction rub noted if secondary to pericarditis.

Pleural effusion.

What is the most common cause of pericarditis? What are the s/s? How do we diagnose? How do we treat?

Post Viral infection Pleuritic chest pain worse lying down and better leaning forward DX: Diffuse ST elevation with PR depression TX: NSAIDS

Shortened, internally rotated, and adducted leg after a motor vehicle accident. Dx and tx.

Posterior dislocation -Must be reduced with 6 hours (to avoid avascular necrosis)

A 44-year-old female presents to the emergency department with a right sided headache. She states the headache is located on the right temple region, is non-radiating, and does not cause photophobia. She is otherwise healthy and has no reported medical problems and has only taken acetaminophen for the pain, which has minimal relief. On physical exam she is alert, awake, and oriented. Her vitals are T 98.8, P 78, R 18, and BP 128/76. Her head is normocephalic, atraumatic, and pupils are equal and reactive. She has tenderness to the right temporal area of the temporal artery, and there is no noted swelling, redness, or abnormalities noted. There is no tenderness to the cervical muscles. She exhibits a non-focal neurological exam. A biopsy of the temporal artery reveals inflammatory cells of the artery wall. Based on the history and biopsy results, what is the best initial treatment for this patient? A Cyclosporine B Azathioprine C Methotrexate D Ibuprofen E Prednisone

Prednisone E This patient is exhibiting a case of temporal arteritis. She has the signs and symptoms that are classic in nature and do not fit into the realm of the other headaches, all of which usually have different characteristics on history and physical exam. In this instance, the use of oral steroids will be the best choice in management of the condition. Anti-inflammatories (C, D) and immunosuppressant agents (A, B) will not be as effective as oral prednisone (E), and the long-term outcomes are improved with steroids.

____is defined as hypertension (>140/90) in pregnancy associated with proteinuria and nondependent edema. Eclampsia are seizures in a pt with pre-elampsia. What is given for seizure treatment? What is the first line treatment for blood pressure control?

Preelampsia; Magnesium Sulfate; Hydralazine

What is diagnostic criteria for Systemic Inflammatory Response Syndrome (SIRS)?

Presence of 2 or more of the following: -Temp > 38 C or < 36 C -Pulse > 90 -Respiratory rate > 20 or PaCO2 < 32 -WBC > 11,000 or < 4,000 or > 10% bands

How do we tx anterior epitaxis?

Pressure for 5-30 minutes...then moistened gauze with epi...then cauterize

What are the contraindications for TPA? (5)

Previous hemorrhage Ischemic stroke/head trauma in last 3 months Known cerebral vascular lesion Aortic dissection Active bleeding

A 42-year-old woman with a history of migraine cephalgia and Raynaud's phenomenon comes to the emergency department with complaints of severe chest discomfort that occurs at rest every morning (at approximately 10 AM). An EKG performed during an episode of chest discomfort demonstrates transient ST segment elevation, which is relieved with sublingual nitroglycerin. There is no troponin elevation. Cardiac catheterization is performed, and reveals coronary artery spasm, which corresponds with ST segment elevation, and no significant coronary artery stenosis. Which of the following choices is the most likely diagnosis? A Pericarditis B Acute myocardial infarction C Costochondritis D Prinzmetal angina

Prinzmetal angina D Prinzmetal angina, or variant angina pectoris, is defined as coronary artery spasm associated with ST-segment elevation, and usually occurs at rest and at the same time of the day. Patients with a history of migraine cephalgia and Raynaud's phenomenon demonstrate Prinzmetal angina more frequently than the rest of the patient population. This can occur in patients with normal coronary arteries and with coronary artery stenosis. Choice A, pericarditis, would present with chest discomfort that is worse while supine and improves with sitting up, as well as a pericardial friction rub. Choice B, acute myocardial infarction, would present with troponin elevation, and is unlikely in the setting of a patient with normal coronary arteries on cardiac catheterization. Choices C and E would not be relieved with sublingual nitroglycerin or demonstrate transient ST-segment elevation.

Most common cause of acute adrenal insufficiency?

Prolonged steroid use with either: -abrupt steroid withdrawal -increased physiological stress (injury, illness)

Erythematous plaques with silver scale and well-marginated. Positive auspitz sign (scales bleed when pulled). Nail pitting. Dx and tx.

Psoriasis -Consult derm -Moisturizer -Topical corticosteroids -Tar -Vitamin D

A 65-year-old male presents with pain and swelling to his right knee without any history of injury. He has had this type of pain and swelling before, and does recall that he had fluid drained out of the knee several years ago. On examination the patient has a swollen, tender knee with a palpable effusion. There is decreased range of motion to the joint secondary to the effusion. An arthocentesis is performed, and the analysis of the fluid reveals calcium pyrophosphonate crystals. Based on these findings, what is the most likely diagnosis? A Septic arthritis B Acute synovitis C Hemarthoma D Pseudogout

Psuedogout D Pseudogout is also known as Calcium Pyrophosphate Deposition Disease (CPDD) and most commonly affects patients over the age of 65. The knee joint is most commonly affected with the wrist joint second most common. An examination of synovial fluid aspirated from the affect joints, will reveal calcium pyrophosphate crystal. Ankle joints are rarely affected by pseudogout but are fairly common locations for gout caused by urate crystal deposition. The first metatarsal phalangeal joint is the classic location for gout (sometimes referred to as podagra), but it is not a typical pseudogout location. The glenohumeral joint of the shoulder is affected by pseudogout much more than gout. Distal interphalangeal joints of the hand are rare locations for either gout or pseudogout, but are classic locations to see signs and symptoms of osteoarthritis. When pseudogout does affect the hands it is generally seen in the metacarpophalangeal joints.

A 36 year-old woman with no significant past medical history presents with gradual onset of dyspnea and fatigue leading to an episode of "fainting" this morning. Physical exam reveals increased jugular venous pressure, weak carotid pulses, clear lungs, and a loud S2. What is the most likely diagnosis? A Aortic stenosis B Cardiac tamponade C Mitral Regurgitation D Pulmonary fibrosis E Pulmonary hypertension

Pulm HTN The patients symptoms are due to decreased cardiac output resulting from decreased preload associated with pulmonary hypertension (E). Aortic stenosis (A) presents more commonly in geriatric patients who present with a murmur. Cardiac tamponade (B) can decrease cardiac output, but would lead to decreased heart sounds. Mitral regurgitation (C) would cause pulmonary edema and rales in conjunction with increased jugular venous pressure. Pulmonary fibrosis (E) is unlikely in this patient with normal lung sounds.

Dyspnea, Tachypnea, Chest pain, Hemoptysis, Elevated d-dimer. Dx and tx.

Pulmonary Embolism -Oxygen -IV unfractioned heparin or LMWH (enoxaparin 1mg/kg) -Emergency cardiology consult -Admit

____is an early systolic opening ejection click followed by a systolic ejection murmur which radiates to the base.

Pulmonic Stenosis

____is most common in first 2 months of life, first born males. Presents with projectile vomiting and "olive-shaped" mass. U/S to image. String sign on upper GI contrast study. What is the definitive treatment?

Pyloric Stenosis; laporoscopic pyloromyotomy

Inflammatory cystic acne on the face of a young woman. Dx and tx.

Pyoderma Faciale -Prednisone -Outpatient referral to dermatology

What virus causes most cases of bronchiolitis? What are the hallmarks signs of this type of infection?

RSV - respiratory syncytial virus; tachypnea, tachycardia, fever, hypoxia

Fever, sore throat, cough, paresthesia followed by agitation, muscle spasms, altered mental status, hydrophobia, dysphagia, hyperreflexia. Dx and tx.

Rabies -Call public health -Debridement of any wound without suturing wound -Human rabies immune globuline -Start rabies vaccine series -Quarantine domestic animals for 10 days

An 18 month old female is brought to the pediatricians office with a history of cough, fever of 102, and decreased fluid intake. Her immunizations are not up to date as the family just moved to the United States from out of the country. On physical exam she is drooling and sitting up in a "tripod position" with mild stridor. What is the most appropriate treatment indicated for this condition? A Humidified air B Albuterol nebulizer C Budesonide nebulizer D Recemic epinephrine nebulizer E Ipratropium nebulizer

Racemic epinephrine nebulizer The clinical presentation suggests epiglotitis. This is an emergent airway condition. The anesthesiologist , or the pediatric otolaryngologist must be called to stand by to intubate or insert a tracheostomy if the patients airway closes. Racemic epinephrine via nebulizer relieves much of the edema to the upper airway in a patient with epiglotitis. It is a stabilizing measure until definitive care can be arranged. Oxygen and antibiotics should administered emergently also. No x-rays are indicated when the presentation is classic. Albuterol is a beta-agonist used for treatment of asthma. Budesonide,a steroid and ipratropium, an anticholinergic agent are most often used in combination with albuterol for treatment emphysema and asthma.

What nerve is most commonly injured in a mid- or distal humeral shaft fracture? A Axillary B Median C Peroneal D Radial E Ulnar

Radial Because of the radial nerves proximity to the humerus, mid and distal shaft fractures with significant displacement can cause a radial nerve injury. Median and ulnar injuries are more commonly associated with forearm injuries. Axillary nerve injuries are most common in anterior shoulder dislocations and peroneal nerve damage occurs as a result of lower leg insult

What are these criteria for? At Presentation: Age>55 WBC>16000 Glucose>200 LDH>350 AST>250 At 48 hours: Fall in HCT>10% Increase in BUN>5mg/dL Calcium<8mg/dL Arterial PO2<60mmHg Base deficit>4mg/L Fluid deficit>6L

Ransom criteria for the prediction of mortality in pancreatitis.

What criteria predict mortality in pancreatitis? what is a high ranson criteria?

Ranson's criteria greater than 6 (70-100% mortality)

What changes might we see with an echo of someone with pericarditis?

Rapid filling during diastole that halts

In hypertensive emergency, what is our goal? Hypertensive urgency?

Reduce by 25% in one hour Reduce diastolic to 100 in 24 hours

A 23-year-old female has been seen in your Emergency Department after being beaten by her husband. As you counsel her before she leaves, which of the following will you recommend? A Avoiding the behavior that brought on the attack B Couples counselling C Leaving the relationship D Prosecuting her husband E Referral to a local women's shelter

Referral to a women's shelter E The appropriate course of action when working with a person who has suffered intimate partner violence is to validate his or her experience, document clearly and non-judgmentally, and assess immediate safety. Referrals to appropriate resources (E) should be made, but decisions regarding the relationship (B, C) and any legal action (D) should be left to the patient rather than continuing a pattern of controlling behavior. Suggesting she avoid behaviors that provoke her attacker (A) puts the blame on the victim.

What is the Kehr sign?

Referred left shoulder pain from a splenic rupture

What is the most common cause of hypocalcemia?

Renal failure

Causes of hypermagnesemia?

Renale failure plus ingestion of either: -Antacids -Lithium

What should you do if you labs suggest an electrolyte abnormality but the symptoms do not suggest it?

Repeat the lab test

Which heat stroke has respiratory alkalosis + lactic acidosis? Which just has respiratory alkalosis?

Resp alkalosis + lactic acidosis = extertional heat stroke Resp alkalosis = nonexertional heat stroke

A 77-year-old male is admitted to the ICU with community acquired pneumonia and sepsis. There is a concern for the possible development of stress gastritis. Which of the following is an important risk factor in the development of stress gastritis? A Platelets < 150,000 per microliter B INR < 1.5 C Patient remaining NPO for > 24 hours D Hematocrit < 35% E Respiratory failure requiring mechanical ventilation > 48 hours

Respiratory failure requiring mechanical ventilation > 48 hours Two of the most important risk factors in the development of stress gastritis are coagulopathy (platelets < 50,000/mcl or INR > 1.5) and respiratory failure, requiring mechanical ventilation for > 48 hours. Hematocrit and amount of time that a patient receives nothing by mouth are not important risk factors.

What is the gold standard imaging for diagnosing suspected bladder injury after trauma?

Retrograde cystogram

An 8-year-old girl is rushed to the emergency department by her parents because she has become delirious. The child was diagnosed with influenza three days prior. Her parents say that she had begun vomiting yesterday, almost nonstop, and has not been able to hold down fluids. They also note that she has been breathing rapidly. Your exam reveals a tachypneic, disoriented female with hyperreflexia, a positive babinski reflex, and liver enlargement. CSF analysis reveals a normal protein and cell count. What is the most likely diagnosis? A Bacterial meningitis B Guillain Barre syndrome C Measles encephalitis D Reye's syndrome E Viral meningitis

Reye's syndrome Although rare, Reye's syndrome is associated with viral infections, salicylate use during illness, and metabolic disorders. Illness is associated with liver fat deposition and degeneration, intractable vomiting, and mental status changes, which may progress to seizures, delirium, and coma. Cerebral edema contributes to these changes and other neurologic findings. Meningeal signs are more consistent with meningitis. Measles encephalitis typically presents days to weeks after the pathognomic measles exanthem and clinical findings. Guillain Barre has been associated with influenza infection, and signs and symptoms would include evolving weakness with ascending paralysis and extremity dysesthesias.

An 18 month infant with congenital heart disease is diagnosed with acute bronchiolitis secondary to respiratory syncytial virus. Which of the following therapies should be initiated? A Albuterol B Amoxicillin C Azithromycin D Prednisone E Ribavirin

Ribavirin High-risk infants (i.e., congenital heart disease) who develop RSV are eligible for treatment with ribavirin. Antibiotics (B, C) are indicated if secondary bacterial infections develop. Albuterol (A) and prednisone (D) haven't been shown to improve RSV-related bronchiolitis.

Loss of consciousness after a head injury, a fixed dilated pupil on the right eye, left-sided paralysis, biconvex shape on CT scan. Dx

Right sided epidural hematoma

Tick bite, fever, headache, myalgia, lymphadenopaty, petechiae, N/V. Maculopapular rash on hands, feet, wrists, and ankles spreading up to the trunk. Dx and tx.

Rocky Mountain Spotted Fever (Rickettsia rickettsii) -Doxycycline

What is the most severe tick-borne disease in the US?

Rocky Mountain spotted fever

A comminuted intra-articular fracture through the base of the first metacarpal bone (base of thumb). Dx and tx.

Rolondos fracture Thumb spica splint

+ Drop Arm Test = ?

Rotator Cuff Tear *(specific?)*

What are some of the PE findings for infective endocarditis?

Roth spots - small white spots on retina surrounded by hemorrhage Osler nodes - small tender lesions on fat pads of fingers and toes Janeway lesions - painless, reddish, macular lesions on hands or feet

Cranial Nerves

S - I -olfactory - smell S - II - optic - vision M - III - oculomotor - EOM M - IV - trochlear - EOM B - V - trigeminal - facial sensation M - VI - abducens - EOM B - VII - facial - frown, puff checks S - VIII - vestibulocochlear (acoustic) - hear B - IX - glossopharyngeal - tongue B - X - vagus - say ahh M - XI - spinal accessory - turn head against resistance M - XII - hypoglossal

A patient presents to the ER after having pituitary surgery earlier in the week. They are peeing often (greater than 3L a day of dilute urine. They also display increased thirst. What is the diagnosis?

S/P surgery DI

Cervical and Lumbar Radiculopathies S1 - motor weakness? decreased reflex? decreased sensation?

S1 motor - gastroc-soleus - flexion/plantar flexion reflex - Achilles tendon sensation - lateral foot

What is the EKG changes in a PE?

S1Q3T3 - with or without a RBBB

What heart sounds are heard with MI?

S3 gallop, diminished S1, paradoxical S2 splitting

Infant with tender skin, diffuse erythema, sand-paper skin followed by large bullae and sloughing of skin. Positive nikolsky sign. Dx and tx.

SSSS (staph scalded skin syndrome) -Admit -Aggressive fluids -Nafcillin IV

Most common foodborne disease causing hospitalization and death?

Salmonella

Infectious diarrhea: ____ is usually caused by contaminated eggs, dairy products, or poulty. ____is usually spread by the fecal-oral route. _____is acquired from eating undercooked poultry or contaminated natural water sources.

Salmonella; Shigella; Campylobacter jejuni

Bloody diarrhea and fever with 24-48 hours of eating bad food. Dx and tx.

Salmonellosis -Cipro

Pruritic papules and burrows in the wrists, fingers, armpits, and belt area. Dx and tx.

Scabies -Premethrin cream from neck down

What is the most common carpal bone fractured?

Scaphoid

Foosh. Snuff box tenderness and pain during radial deviation. Dx and tx.

Scaphoid fracture Thumb spic splint or Radial gutter splint

Fresh water exposure, maculopapular dermatitis over lower legs that itches followed by fever, urticaria, headache, diarrhea, hypereosinophelia. Dx and tx.

Schistosomiasis (Snail Fever) -Praziquantel

A 39-year-old male patient presents with low back pain with radiation to the right leg. On examination you place the right hip in a flexed position, and as you palpate between the iscial tuberosity and the greater tronchanter of the femur the patient complains of radiation of pain down his right leg. Based on this history and exam, which nerve was affected by this part of the examination maneuver? A Femoral B Peroneal C Saphenous D Sciatic E Sural

Sciatic D The sciatic nerve does lie midway between the ischial tuberosity and greater trochanter and it can be palpated when the patient is in a hip flexed position. The gluteus maximus obscures the nerve from being effectively palpated when the leg is in an extended position. Tenderness of the sciatic nerve can be caused by a lumbar disk herniation, direct trauma, or spasm of the nearby pyriformis muscle. The femoral nerve is a deep structure that lies lateral to the femoral artery and is not considered to be palpable. The femoral nerve is responsible for the L1-3 dermatomes and for supplying motor function to the iliopsoas muscle. The peroneal nerve originates from the sciatic nerve and splits into the superficial and deep peroneal nerves, which are responsible for much of the sensory and motor nerve function in the lower leg. The saphenous nerve originates from the femoral nerve in the femoral triangle and runs down the medial aspect of the leg. The sural nerve has medial and lateral components that are found in the lower leg. The medial cutaneous sural nerve arises from the tibial nerve just below the knee and eventually connects with peroneal nerve to form the sural nerve. On the lateral side of the lower leg, the sural nerve arises from the common peroneal nerve just above the knee and eventual connects with the previously discussed medial branch to form the sural nerve

Immediate pain and parasthesia of extremity after a sting. Positive "tap" test (extreme local pain when area is lightly tapped). Tachycardia, N/V, roving eye movements, muscle spasms, vision impairment, dysphagia. Dx and tx.

Scorpion venom -Analgesics -Benzos -Antivenom if severe

Greasy yellow scales on chest and face. Dx.

Seborrheic dermatitis

A 16-year-old male soccer player is complaining of pain to the right foot that has been getting progressively worse for the last 2 months. He states it hurts the most when he has all of his weight on his right foot as he plants to kick the ball. Most of the pain appears to be on weight bearing. You are concerned that this patient may be developing a stress fracture. Based on the patient's history and patient presentations, which bone is the most affected by stress fractures in the foot? A Calcaneus B Fifth metatarsal C First metatarsal D Second metatarsal E Talus

Second Metatarsal Any bone that is exposed to repetitive stress can have a stress fracture, but the long and thin metatarsal bones of the foot are the most commonly affected bones. Of the metatarsals, the second metatarsal has the highest number of stress fractures. These weight bearing bones can be particularly vulnerable to stress fracture if the patient is involved in long distance running, especially if he/she is wearing improper footwear for that activity or footwear that has lost most of its shock absorbing abilities. Some young female athletes may be training so hard that they become amenorrheic which can contribute to osteopenia resulting in weaker bones. Older patients with osteoporosis will also have a higher risk of stress fracture. Initially stress fractures of the metatarsals may present with a small area of localized pain and the dorsal forefoot may demonstrate a fairly diffuse area of swelling. If the stress fracture is not treated early, some patients will experience an audible pop or crack as the incomplete stress fractures progresses to a complete break. All types of fractures occur more easily in long thin bones like the metatarsals, than thicker bones like the calcaneus and talus

It is vital to make sure the symptoms of the first concussion have subsided because of the gloomy possibility of ________ ie. when the brain swells catastrophically - patient either dies or is left severely disabled.

Second impact syndrome

Altered mental status, tachycardia, tachypnea, hypotension, hot flushed skin, oliguria, hyperglycemia, WBC abnormalities, thrombocytopenia. Dx and tx.

Septic Shock -Airway management (usually intubation) -Rapid IV crystalloids -Vasopressors -Imipenem or Pip/Tazo or Cefepime -Admit to ICU

Aspiration of joint reveals: yellow, cloudy fluid with >50,000 WBCs and >50% PMNs. Dx.

Septic arthritis

____is hematogenous spread of bacteria to synovial membrane lining the joint. Common organisms are S aureus, Neisseria gonorrhea, gram-negative bacilli, parvovirus B19, Hep B, Mumps

Septic arthritis

What is the most common condition associated with acute lung injury and ARDS?

Septic shock

A 68-year-old woman with a history of hypertension and diabetes mellitus type 2 comes to the emergency department with her son, who noticed that while decorating for Christmas she seemed more dyspneic than normal, and had to sit down frequently. In addition, he noticed that she was pale and diaphoretic, and insisted on driving her to the emergency department. On questioning, she denies chest pain, but admits to being more fatigued than usual, with frequent jaw discomfort during activity. Activities such as vacuuming her house cause dyspnea, and she now has to stop several times while carrying laundry up from the basement. On physical examination, the patient's blood pressure is 90/50, pulse 99 bpm, respirations 22, and she is afebrile. Auscultation of the chest demonstrates a new systolic murmur. An EKG demonstrates normal sinus rhythm with nonspecific ST and T wave changes. Which of the following would be the most appropriate next step in the management of this patient? A Transesophageal echocardiogram B Nuclear stress test C Cardiac catheterization D Serial serum troponin levels E CXR

Serial serum troponin levels Choice D, checking serial serum troponin levels, is the most appropriate next step in the management of this patient. Women and diabetics may present with atypical symptoms with acute non-ST-segment myocardial infarction, including dyspnea, jaw discomfort, and epigastric discomfort. Frequently, women present much later than men with these symptoms. Therefore, a high level of suspicion should be maintained when women present with symptoms of dyspnea, even in the setting of nonspecific EKG changes, and drawing serum troponin levels before any other testing is recommended. Once non-ST-segment myocardial infarction has been ruled out, choices E and B, and also transthoracic echocardiogram, would likely be evaluated. Transesophageal echocardiogram may be required if better visualization of the heart valves is required, but not as the next step. Choice C, cardiac catheterization, would likely occur if an abnormal stress test demonstrating symptoms of myocardial ischemia is found.

What is the main method for confirmation of arboviral infections?

Serologic tests for antibodies

A 17 year-old patient presents to the emergency department with agitation and hallucinations, and has one seizure. He admits to using "some drugs" but does not know what they were. On physical examination, temperature is 103 degrees F, BP 140/90, pulse 120, respirations 20. Remainder of the examination is unremarkable. Which of the following diagnostic studies will be of most help in managing this patient? Why wouldnt we do a drug screen?

Serum creatinine Kinase- we are concerned about rhabdomyolosis with the seizures and high temp Because it would not change the treatment course

Dry mucosa, shrunken tongue, decreased skin turgor, tachycardia, hypotension. Dx and tx.

Severe dehydration -D51/2NS + potassium chloride

Abrupt onset diarrhea with blood and mucous, fever, tenesmus, malaise. Dx and tx.

Shigellosis -Cipro

Hypotension, tachycardia, tachypnea, oliguria, altered mental status, cool clammy skin, delayed capillary refil, mottling of the skin. Dx.

Shock

An 80-year-old male nursing home patient is brought to the emergency department with abdominal distension. A plain film of the abdomen is pictured below. Which of the following is the most likely diagnosis? Picture of a "coffee bean" looking abdominal x-ray. A Small bowel obstruction B Cecal volvulus C Sigmoid volvulus D Toxic megacolon

Sigmoid Volvulus A volvulus is an obstruction of the colon due to a loop of bowel that has rotated more than 180 degrees on its axis with the mesentery. The most common site for a volvulus is the sigmoid colon (65%). A sigmoid volvulus is associated with abdominal pain and distension. Plain films of the abdomen would show a characteristic "bent inner tube" appearance. Sigmoidoscopy can be used to decompress the bowel by gently releasing the area of obstruction. Following decompression, a rectal tube is inserted to act as a stent to prevent the bowel from twisting upon itself again.

In ____ seizures, consciousness is maintained. In ____, there is a loss of consciousness, indicating the spreading or generalizing to both cortical hemispheres.

Simple partial; Complex partial

How are burns categorized?

Size: according to rule of 9's Depth: superficial partial thickness, deep partial thickness, full thickness

What is the Nikolsky sign?

Slippage of the epidermis from the dermis with slight rubbing/pressure

Whata anatomical features cause periumbilical pain?

Small intestine, appendix, and proximal colon

____lesions have a depression in the center, spread from the face/arms to trunk/legs, and are all at the same stage.

Small pox

Distal radius fracture fragment angled volarly. Dx and tx.

Smith fracture (wrist/hand below forearm) -Closed reduction and sugar tong splint

Antidote → TCAs

Sodium Bicarb

Tx for Leishmaniasis?

Sodium stibogluconate (available through CDC)

A 42-year-old healthy male presents to the emergency department with the complaint of a progressively worsening sore throat, and difficulty swallowing over the past 48 hours. He also complains of a subjective fever, but denies any headaches, nausea, or vomiting. On exam, the patient is afebrile and in mild distress, with a presentation of leaning forward on the exam table. His TM examination is normal, there is no rhinorrhea, and the oropharynx is patent without signs of stridor. His lungs are clear, and he has a regular rhythm on cardiac exam. What diagnostic test is indicated for a definitive diagnosis? A Chest x-ray B Complete blood count (CBC) C Nasal bacterial culture D Soft tissue neck x-ray E CT scan of the neck

Soft tissue neck Xray D This patient has a presentation that is consistent with acute epiglottitis. While ensuring that the airway is patent and the patient can maintain the airway, the first step in determining the diagnosis is a soft tissue neck x-ray, to determine inflammation to the epiglottis. While rare, epiglottitis can be from a bacterial infection, and can be quite serious and sometimes fatal.

Trauma to the abdomen and then tachycardia, hypotension, acute abdominal tenderness. Dx.

Solid visceral organ injury (spleen or liver)

Temporary loss of reflexes after trauma to the spine. Dx and tx.

Spinal Shock -Oxygen -IV fluids -Vasopressors if needed

Low back pain the worsens with walking and improves with rest. Dx.

Spinal stenosis

What is the most common injured organ in blunt abdominal trauma?

Spleen

What is a positive Kehrs sign indicative of?

Splenic rupture

A patient presents with pain in the left upper quadrant. Imaging shows intraperitoneal blood. Pt has rebound tenderness. What is the suspected diagnosis? How do we diagnose?

Splenic rupture Ultrasound

Patient cut self in the dirt and now has painless nodules starting at the cut and moving up along lymphatic channels. Dx and tx.

Sporotrichosis -Itraconazole po

_____angina is brought on by activity/exercise. ____angina may show transient ST changes and inverted T waves. ____is pain mainly occurring at rest due to vasospasm of coronary arteries.

Stable, unstable, prinzmetal/variant (responds well to CCB or nitrates, BB may exacerbate vasospasm)

Bacteria involved in Toxic Shock Syndrome?

Staph aureus

Most common cause of spinal infection (e.g., spinal epidural abscess or spondylitis)?

Staph aureus

Osteomyelitis is infection of the bone that may occur from a variety of methods. What are the most common organisms?

Staph aureus, E Coli, Pseudomonas aeruginosa, Salmonella (common in sickle cell)

Erythema multiforme that has spread to mucous membranes is known as...

Steven Johnson syndrome

Diffuse vesiculobullous lesion on skin and oral, conjunctival, and genitourinary mucosa. Fever, hypotension, electrolyte deficiency. Dx and tx.

Steven Johnson syndrome -ICU admit -Fluids -Diphenhydramine and lidocaine (for symptomatic relief) -Cool burrow solutions applied to blisters

TEN and SJS typically evolve after exposure to certain drugs or infections - like sulfonamide, anticonvulsants, herpes virus). If less than 10% of body is affected, it is aka ____. If greater than 30% of the body is affected, it is aka ____.

Steven Johnsons Syndrome; Toxic epidermal necrosis

A 52 year-old female comes to the office because of black stools for the past 3 days. She is afebrile and she has no pertinent physical examination abnormalities. Which of the following is the most appropriate initial diagnostic study?

Stool for occult blood is necessary to verify blood in stool before further work-up

With pharyngitis, what bacteria is found in rapid strep test? Centor score: absence of cough, fever, tonsillar exudate, tendor/swollen anterior cervical lymph nodes

Strep pyrogenes

Endocarditis (or infection of the endothelial surface of the heart) is most commonly caused by what bacteria?

Strep viridans, Staph aureus, and Enterococcus

Soft tissue pain/inflammation localized to one area. Pain out of proportion to findings. Fever. Hypotension. Multisystem organ failure. Dx and tx.

Streptococcal Toxic Shock Syndrome -Admit to ICU -Aggressive fluid resuscitation -Intubation (due to high likelihood of ARDS) -Penicillin + Clindamycin IV -Immediate surgical consult for debridement, fasciotomy, or amputation

What type of fracture is not related to an acute bony trauma? A Greenstick B Stress C Oblique D Comminuted E Spiral

Stress B A stress or fatigue fracture is caused by small, repetitive forces that usually involve the metatarsal shafts, the distal tibia, and the femoral neck (though many other bones may be affected). These fractures may not be seen on initial radiographs. A greenstick fracture is an incomplete traumatic fracture with angular deformity seen in children. An oblique fracture is a traumatic fracture with an angulated fracture line. A comminuted fracture is a traumatic fracture in which there are more than two fracture segments. A spiral fracture is a traumatic fracture that has a multiplanar and complex fracture line usually caused by an excessive rotational force on a bone.

____hematoma is an aneurysm presenting with a thunderclap headache, stiff neck, and delirium.

Subarachnoid

A 24 y/o M patient has had two syncopal episodes in the last 3 years. He can only recall that his syncopy happened while working out his right bicep at the gym on both occasions. What is the likely cause of the syncope?

Subclavian Steal syndrome

_____hematoma involves injury to a vein and symptoms develop later after head injury with headache, confusion, coma, and hemiparesis. Often after acceleration-deceleration injuries.

Subdural

Lethargy, headache, and hyperdense crescent-shaped lesion on CT scan. Dx.

Subdural hematoma

Describe pain location, type, radiation, and other ss with... pericarditis

Substernal, sharp constant pain with pericardial friction rub and fever

An HIV-positive patient presents with worsening dementia, fever, headache, and right hemiparesis. MRI of the brain reveals six lesions throughout the brain that show ring enhancement and surrounding edema. Which of the following is the treatment of choice?

Sulfadiazine and pyrimethamine

A pt presents to the ER for a burn. It has pink clear blisters, it involves the epidermis and upper dermis, and is very painful. What kind of burn and how long is healing?

Superficial second degree burn...takes about 2-3 weeks to heal

A 1-year-old boy is brought to the emergency department by his parents, who state that the child refuses to walk or crawl and begins crying when they stand him. He seems calm while lying on the examination table. Vitals are as follows: Temp: 38°C, HR: 70, RR: 15. Bruising is noted in several places. His parents deny trauma, but have noticed that he bruises easily. What other physical finding would you expect? A Conjunctival hemorrhages secondary to shaken baby syndrome B Pain response over the wrists secondary to passive range of motion C Pain response with passive range of motion to the hip secondary to slipped epiphysis D Pharyngitis and sand paper rash secondary to a staph infection E Swelling and warmth over the knee secondary to hemarthroses

Swelling and warmth over the knee secondary to hemarthroses This patient has hemophilia A. Hemarthroses usually occur when an affected child begins to walk. Due to his hemophilia, easy bruising can occur. Hemarthroses can cause low-grade fevers without infection being present, so choice D is incorrect. Wrist joints are less involved then knees, ankles, and elbows.

Painless ulcer with indurated borders on penis or vulva. Dx and tx.

Syphilis -Benzathine penicillin G IM

A firm, painless vaginal ulcer is seen with...?

Syphillis

Stung by insect followed by itchy eyes, urticaria, and cough within 6 hours. Dx and tx.

Systemic/anaphylactic reaction to Hymenoptera -EPI IM -Normal saline -Diphenhydramine -Steroids -Albuterol (if bronchospasm) -Prescribe EPI Pen

What are the three qualifications for malignant HTN?

Systolic greater than 220, diastolic greater than 129, symptoms of end organ damage

Where are most thoracolumbar fractures located?

T12-L4

A 33-year-old IV drug user presents to the emergency department with chills, diaphoresis, anorexia, and malaise. On physical exam, her temperature is 40C, BP 98/55, P 115 bpm, and RR 22. Two separate blood cultures are positive for S.aureus. Which of the following diagnostic studies would be most useful in establishing this patient's diagnosis? A EKG B CXR C Rheumatoid factor D ESR E TEE

TEE E Choice E, TEE (or transesophageal echocardiogram), would be most useful in establishing a diagnosis of infective endocarditis, as a positive echocardiogram demonstrating presence of a vegetation would satisfy one of the Duke criteria's major criteria. TEE is more sensitive than TTE (transthoracic echocardiogram) for detecting vegetations. EKG and CXR should be performed as part of this patient's evaluation, but would be less useful than TEE in establishing a diagnosis of infective endocarditis. ESR and rheumatoid factor are frequently elevated in patients with endocarditis, but are not specific to the diagnosis of endocarditis.

A 55-year-old right-hand dominant man presents with a 4-hour history of weakness and tingling of his right hand and numbness of the right side of his mouth. Mild difficulty was noted with word finding. His symptoms have improved since onset but have not fully resolved. There is no significant medical history. Physical examination revealed flat right nasolabial fold, subjective numbness of the right hand, right pronator drift, clumsiness of finger tapping on the right hand, increased deep tendon reflexes on the right, as well as a present Babinski. What is the most likely etiology for this patient's problem? A migraine headache B peripheral neuropathy C syncope D transient ischemic attack E seizure

TIA D Three key features of a transient ischemic attack include sudden onset and complete reversal of symptoms within 24 hours, usually within 15 minutes. The symptoms are usually in the anatomical distribution of a single blood vessel. This patient's history is not suggestive of migraine or syncope. His physical examination findings do not correlate with peripheral neuropathy or seizure.

A 24-year-old HIV-positive man comes to the emergency department complaining of severe left-sided chest discomfort, which radiates through to the left trapezius region. On coming into the room, you note that he is sitting up and hunched forward. On physical examination, the patient's blood pressure is 135/78, with a pulse of 85 bpm, and a pericardial friction rub is noted. Laboratory findings demonstrate elevated serum creatine kinase levels and normal serial troponin levels. His EKG demonstrates peaked T waves. His CXR demonstrates a "water bottle" cardiac silhouette. Which of the following diagnostic studies would be considered the most appropriate next step in management of this patient? A Cardiac catheterization B Transthoracic echocardiography C CT of the thorax D VQ scan

TTE B Choice B, transthoracic echocardiography, would allow for monitoring of a patient with acute pericarditis, to determine if a pericardial effusion and/or cardiac tamponade develops. Choice A, cardiac catheterization, would be appropriate in a patient with acute myocardial infarction. Choice C, CT of the thorax, is not as effective or specific as transthoracic echocardiography for the development of a pericardial effusion and/or tamponade. Choices D and E would be appropriate diagnostic studies if pulmonary embolism is suspected, but not as the next step in management of this patient with pericarditis

A 55-year-old woman with a history of hypertension and 2 vessel CABG presents to the emergency department with increasing dyspnea while walking up one flight of stairs. She denies chest pain and discomfort, but states that for the last 2 weeks she has also noticed palpitations. On physical examination, her vital signs are stable, with a normal physical exam. On EKG, she demonstrates atrial flutter with 2:1 AV block. Which of the following is the most appropriate next diagnostic study for this patient? A Transthoracic echocardiogram B Cardiac catheterization C Nuclear stress test D Holter monitor E Event recorder

TTE Choice A, transthoracic echocardiogram, is the most appropriate next diagnostic study in this patient with atrial flutter, as it can demonstrate the presence of valvular heart disease. The presence of valvular heart disease can change the recommendations for embolism prophylaxis. Atrial flutter is treated similarly to atrial fibrillation in terms of embolism prophylaxis. Choice B, cardiac catheterization, is useful in patients suspected to have unstable angina, or who have sustained a myocardial infarction. Choice C, nuclear stress test, is useful in patients suspected to have angina pectoris, and may be a useful diagnostic study in this patient with cardiac risk factors once the issue of atrial fibrillation has been treated. Choices D and E would be useful tests if the EKG had not established a diagnosis for this patient, with the Holter monitor indicated in patients experiencing symptoms on a daily basis, and the event recorder indicated in patients demonstrating more sporadic symptoms

Pain and stiffness in the jaw, "sarcastic grimace" facial expression, persistent rigidity of muscles, violent spasms of extremities, dysphagia, normal mentation. Dx and tx.

Tetanus -Admit to ICU -Tetanus immune globulin -Td booster -Midazolam -Debridement of inciting wound

A 59-year-old woman presents to the accident and emergency department by ambulance with second- and third-degree burns to her head and neck, and the anterior surfaces of her upper extremities, right leg, and trunk including her genital area. Question Which of the following represents a reasonable estimation of the extent of her burns? Answer Choices 1 36% 2 37% 3 46% 4 45% 5 55%

The correct answer is 55%. This estimation is based on the "rule of 9s". Body surface area is estimated at 9% for each arm, the head and neck, anterior surface of upper torso, anterior surface of lower torso, posterior surface of upper torso, posterior surface of lower torso, anterior surfaces of each leg, posterior surfaces of each leg and an additional 1% for the groin area for a total of 100%. In this case, 9% for her head and neck, 9% for the anterior surface of each arm, 9% for the anterior surface of her right leg, 9% for her anterior upper torso, 9% for her anterior lower torso, and 1% for the genital area for a total of 55%. The other answers are incorrect using the estimation by the "rule of 9s".

What test is diagnostic of achilles tendon rupture?

Thompson test (no plantar flexion when calf is squeezed)

First Trimester Vaginal Bleeding: ____abortion has closed cervical os with no POCs expelled. ____abortion has open cervical os with no POC's expelled. ____abortion has open cervical os with some POC's expelled. ____is has closed cervical os with all POC's expelled.

Threatened; Inevitable; Incomplete; Complete

Fever, agitation, confusion/delirium, seizures, tachycardia, arrhythmia, CHF. Dx and tx.

Thyroid Storm (from Graves disease) -Oxygen -PTU -Propanolol -Cooling (for hyperthermia) -Admit

The most commonly fractured long bone in both adults and children is which of the following? A Femur B Fibula C Humerus D Radius E Tibia

Tibia The tibia is the most commonly fractured long bone in the body for both adults and children. The fractures are often the result of sporting activities in the young and may occur from a simple fall in the elderly - especially those with osteoporosis. Motor vehicle accidents are another common cause of tibial fractures. Open or complex tibial fractures are sometimes associated with compartment syndromes, infection and neurovascular compromise. The femur is the strongest of the long bones and generally only sustains fractures when exposed to extreme stress, such as that experienced in a motor vehicle collision or industrial accident. Fibular fractures commonly occur with a direct below to the lateral lower leg or with extreme ankle rotational forces or excessive inversion. A high percentage of ankle fractures involve the fibula, especially in older women. Humerus fractures are relatively rare in adults, but are the second most common fractures to occur at birth - behind only the clavicle in frequency. The radius is the most commonly fractured bone in the upper extremity, but still less common in frequency than the tibia. Falls on an outstretched arm are a common mechanism for the injury.

A 46-year-old male is evaluated for a fall from approximately 15 feet, landing on his legs. There is intense pain and swelling to the lower extremity, with decreased sensation. What bone is fractured and is most commonly associated with acute compartment syndrome? A Femur B Patella C Navicular D Talus E Tibia

Tibia he tibia is the most common bone fracture that leads to acute compartment syndrome. It can also occur after other long bone fractures of the arms and legs. While it does occur in the hands and feet, it is unlikely that the fracture of a small carpal bone (scaphoid) or tarsal bone (talus) would result in compartment syndrome. Damage to the hyoid bone in the neck and the patella in the knee are not associated with compartment syndrome.

A key differential for Guillain-Barre should always be...

Tick neurotoxin (has same ascending flaccid paralysis as GB)

What is the most common vector of disease transmission?

Ticks

How do we treat glaucoma?

Timolol or prostaglandin analog drops

Circular plaque covered with scales and surrounded by a raised border on the trunk. Dx and tx.

Tinea Corporus -Clotrimazole topical

Inflammatory plaques and follicular pustules in the beard area. Dx and tx.

Tinea barbe -KOH prep -Griseofulvin po + Selenium sulfide shampoo

Patchy areas of alopecia with broken off hairs and scales at the periphery. Dx and tx.

Tinea capitis -KOH prep -Griseofulvin po + Selenium sulfide shampoo

Erythema on thighs and buttocks with a annnular scaly edge. Dx and tx.

Tinea cruris (jock itch) -Clotrimazole topical

Interdigital scaling, maceration, erythema of the soles or palms, itching. Dx and tx.

Tinea pedis/manuum -Clotrimazole topical

Malaise, anorexia, fever, URI for 1-2 weeks followed by erythroderma (extensive erythema), bullae, erosions, and exfoliation (skin peeling off). Positive nikolsky sign. Dx and tx.

Toxic Epidermal Necrolysis (TEN) -ICU admit -Emergent derm consult

Stung by insect followed by GI problems with no bronchospasm or urticaria. Dx and tx.

Toxic reaction to Hymenoptera -Antihistamines -Analgesics -Remove stinger and clean wound with soap/water -Ice and elevation (to reduce swelling) -Prescribe EPI Pen

High fever, hypotension, diffuse erythema and "painless sunburn" with desquamation, mucus membrane hyepremia, myalgia, lethargy, confusion, N/V, diarrhea, abdominal pain. Dx and tx.

Toxic shock syndrome -Aggressive crystalloid fluids = most important -Remove any FBs (tampons, piercings, nasal packing) -Nafcillin + Clindamycin -Consult surgery -Admit

Transudates vs. Exudates: ______occur when systemic factors that control formation and absorption of pleural fluid are altered. Left sided heart failure/cirrhosis. ______occur when local factors that control formation and absorption of pleural fluid are altered - pneumonia, malignancy, viral infex, PE

Transudates; Exudates

The types of dermatitis are atopic, contact, nummular eczematous, perioral, seborrheic, and stasis.

Treatment, depending on cause, is usually centered on removing allergen and skin hydration.

What organism causes syphilis?

Treponema pallidum (spirochete)

Active elbow extension is primarily controlled by which muscle(s)? A Anconeus B Biceps C Brachialis D Brachioradialis E Triceps

Triceps E The triceps are the primary muscles that produce active elbow extension. The anconeus muscle is known as a secondary elbow extensor. The biceps and brachialis muscles are primary muscles of elbow flexion and the brachioradialis is a secondary elbow flexor.

Vaginitis with intense vaginal pruritis. Malodorous yellow-green vaginal discharge and urethritis. Dx and tx.

Trichomoniasis -Saline wet prep (shows motile, flagellated organism) -Metronidazole 2 grams po single dose

_____is blowing and musical best heard along left sternal border.

Tricuspid regurgitation

Cardiac Markers: _____is the test of choice and appears 2-6 hours after MI and stays elevated for 5-10 days.

Troponin

Myocardial Necrosis: -Most sensitive lab to check?

Troponins

Tick bite, papule at site of tick bite, painful regional adenopathy. Dx and tx.

Tularemia (ulceroglandular form) -Streptomycin

What is Chvostek sign?

Twitch of the corner of the mouth on tapping finger over CN 7 at the zygoma Indicates hypocalcemia

What differentiates the different types of von Willebrand disease?

Type 1 (MC) = 20-50% normal vWF levels Type 2 = abnormal or dysfunctional vWF Type 3 = complete vWF deficiency

What are the four types of pelvic fracture?

Type 1 = individual bone fracture Type 2 = single break in pelvic ring Type 3 = double break in pelvic ring Type 4 = fracture of the acetabulum

Which type(s) of Salter-Harris fractures can generally be treated with closed reduction and cast immobilization? A Type I B Types I and II C Types I, II, and III

Type 1, 2, and 3 Minimally displaced Salter-Harris types I, II, and III fractures generally can be treated with immobilization only. Types IV and V involve the cartilage of both the articular surface and the growth plate. To ensure proper alignment and a congruous joint surfaces open reduction and internal fixation is usually necessary.

Aortic dissections - Stanford type A vs. Stanford type B. What's the difference and which is treated surgically?

Type A - involves ascending aorta - surgical tx!!! Type B - involves descending aorta - BP control

Recent travel with fever, cough, abdominal pain, constipation, prostration, bradycardia followed by pale red macular rash ("rose spots") on trunk. Dx and tx.

Typhoid Fever -Fluids -Tylenol for fever -Cetriaxone

Most common injury leading to Septic Shock?

UTI

A 46-year-old female presents to the emergency department with a complaint of hematemesis, nausea, and epigastric pain. The hematemesis started earlier this morning, while the epigastric pain started three days prior and was a dull ache. She has vomited three times. She denies fever, diarrhea, or weight loss. She has not had blood in her stool. Her current medications include ibuprofen. She has been taking this medication daily for the past three months for right knee pain. What is the test that is the most sensitive for diagnosing this disease process? A Upper endoscopy B Hemoccult test C Esophageal manometry D Barium esophagography E Urea breath test

Upper endoscopy A The correct answer is upper endoscopy. The most likely diagnosis is gastritis, and upper endoscopy is the most sensitive method of diagnosis. Hemoccult testing is used to detect the presence of blood in the patient's stool. Esophageal monometry is used most often in establishing an etiology of dysphagia. Barium esophagography is also used frequently in the evaluation of patients with dysphagia. Neither esophageal manometry or barium esophagography would help you determine the source of this GI bleed. Urea breath test is used in detecting H. pylori infection, but would not be the best choice in diagnosing gastritis.

_______refers to inflammation of the urethra. Gonococcal produces a thick, purulent urethral discharge and burning with urination. Nongonococcal presents with dysuria and scant urethral discharge. May be suggested if urine dipstick test for leukocyte esterase is positive and no bladder infection is present.

Urethritis

What is the PERC criteria?

Used to assess risk of a PE

What is the initial, intermediate, and final diagnostic imaging for PE?

V/Q scan, CT, and pulmonary angiography

What is the initial treatment for a patient who is having an acute episode of supraventricular tachycardia? A Caffeine B Beta blockers C Valsava maneuver D No treatment E Synchronized cardioversion

Valsalva maneuver The initial treatment that should be attempted is a simple vagal maneuver to break the reentry tachycardia. If this is unsuccessful, pharmacologic therapy is indicated.

Fever, malaise, vesicular rash with lesions at various stages on face and trunk. Dx and tx.

Varicella chicken pox -Acyclovir if immunocompromised or older > 12 yrs old

What are the top four causes of syncope and in what order? Of these, which is the most related to death?

Vasovagal, cardiac, orthostatic, and medication Cardiac

Pt presents with normal peripheral pulses, edema, medial skin ulceration...diagnosis?

Venous insufficiency

What is the most reliable test to diagnose CO poisoning?

Venous or Arterial blood sample for cooximetry (i.e., COHb carboxyhemoglobin)

____arrhythmia most frequently results from lower energy AC exposures whereas ____is more common after exposure to higher energy DC.

Ventricular fibrillation; asystole

Osteomyelitis in adult itravenous drug abusers most commonly affects which bones?

Vertebral spine

Swimmer in ocean gets cut/bit and develops hemorrhagic bullae, vasculitis, necrotizing fasciitis. Dx and ts.

Vibrio (gram negative bacillus) -Ceftriaxone or Fluoroquinolone

Acute bronchitis is usually caused due to ____ie. Adenovirus, Influ A or B, Coronavirus, Rhinovirus, RSV. ______causes include H flu, Mycoplasma pneumonia, M cat, Chlamydia pneumo, or Strep pneumo.

Viruses; Bacterial

Which of the following is the most reliable clinical tool for confirming endotracheal intubation in an emergency situation? A Auscultation over the stomach B Endotracheal tube condensation C Pulse oximetry monitoring D Sellick maneuver E Visualizing the tube passing through the vocal cords

Visualizing the tube passing through the vocal cords Clinical assessments and practices used to assess tube placement, and help with placement, such as auscultating for breath sounds and noise within the stomach, have not had a confirmation rate comparable to directly visualizing the tube passing through the vocal cords. Tube condensation may occur with esophageal intubation as well. The Sellick maneuver may help with correct positioning, but is not a confirmatory test. Once placement is suspected, confirmation with an end-tidal CO 2 detector and chest x-ray is recommended. Pulse oximetry measurement should be performed throughout the intubation, with decreased saturations representing a worsening clinical condition and/or esophageal intubation.

A 52-year-old male with chronic alcoholism is brought to the emergency department by his family, due to his acting differently for several days. A physical exam reveals nystagmus, eye muscle weakness, global confusion, retrograde amnesia, and ataxia. Which of the following is the most likely etiology of the diagnosis? A Cerebrovascular accident B Hypoxemia C Uremia D Vitamin B12 deficiency E Vitamin B1 (thiamine) deficiency

Vit b1 deficiency E This patient exhibits classic symptoms associated with Wernicke encephalopathy. Wernicke encephalopathy is due to vitamin B1 (thiamine) deficiency. In the United States, this condition occurs most frequently in chronic alcoholics, but it may be seen in any condition affecting thiamine levels. Each of the other etiologies listed may also cause neurologic findings, and should be considered in the differential diagnosis and evaluation of this patient.

What is the most commonly used anticoagulant therapy in the US?

Warfarin

A 55-year-old woman with a history of mitral stenosis (secondary to rheumatic heart disease) presents to the emergency department with increasing dyspnea while walking up one flight of stairs. She denies chest pain and discomfort, but states that for last 24 hours she has also noticed palpitations. She also admits to lower extremity edema, which is new within the last week. On EKG, she demonstrates atrial flutter with 2:1 AV block. Which of the following is the most appropriate therapy for this patient? A Aspirin 325 mg B Plavix 75 mg C Plavix 75 mg and aspirin 81 mg D Warfarin, dosed to INRs between 2.0 and 3.0 E Dipyridamole 200 mg and aspirin 25 mg

Warfarin, dosed to INRs between 2.0-3.0 Patients with atrial flutter of less than 48 hour duration may be cardioverted without anticoagulation, unless they have mitral valve disease, in which case they should be treated with warfarin; therefore, choice D is the most appropriate choice. Choices A, B, C and E are inappropriate, as there is no data to support that any of these therapies offer adequate anticoagulation for embolism prophylaxis, for either atrial fibrillation or atrial flutter. Choice A is recommended for cardiac risk factor modification for men, according to the Framingham Risk Trial. Choice C is appropriate therapy following PTCA and stent placement.

Hymenoptera refers to...

Wasps, bees, and stinging ants

Fever and headache following a mosiquito bite. Dx and tx.

West Nile Virus -Supportive tx

What are the two signs of PE on CXR?

Westermark's sign - area of decreased pulmonary vascularity with a cutoff sign Hampton's hump - shadow or density in contact with one or more pleural space corresponding to lung segment involved

When should Rhogam be given in pregnancy?

When the mom is Rh-negative and the baby is Rh-positive. Mom may develop antibodies to the Rh antigen and cause hemolysis of the fetal red blood cells in subsequent pregnancies

What is the goal of immediate trauma care?

Within the 1st hour (golden hour): -Rapidly assess patient -Initiate resuscitation and stabilization -Establish priorities of care -Treat -Perform diagnostics

Which patients typically experience atypical chest pain with MI?

Women, diabetics, elderly, and psychiatric pts

What two aggravating factors are known with pericarditis? What PE finding is most noted?

Worsened when lying flat and with inspiration Pericardial friction rub

Recent travel with fever, headache, conjunctival injection, facial flushing followed by jaundice, black emesis, and albuminuria. Dx and tx.

Yellow fever (Flavivirus) -Supportive tx -Transufsions (possibly)

Infectious diarrhea: ____produces a clinic syndrome similar to appendicitis. Spread via fecal-oral route. ___is most commonly acquired from eating undercooked beef. Can cause hemolytic uremic syndrome and thrombotic thrombocytopenic purpura. A protozoa, _______, is one of the principal agents of traveler's diarrhea.

Yersinia; E Coli; Giardia lamblia

The term "nursemaid's elbow" refers to which of the following physical conditions? A A fracture of the humerus B A subluxation of the radial head C Inflammation at the lateral epicondyle D Inflammation of the medial epicondyle E Olecranon bursitis

a subluxation of the radial head B This is the most common elbow injury in children under the age of 5. The injury generally occurs when the child's arm is forcefully pulled when the elbow is in an extended position and the forearm is pronated. Fibers of the annular ligament that encircle the radial neck become trapped between the radius and ulna. On presentation, children hold their arm in slight flexion and pronation. There is no fracture associated with nursemaid's elbow and the olecranon bursa is unaffected. Nursemaid's elbow is an acute injury, while medial and lateral epicondylitis (also known as golfer's elbow and tennis elbow respectively) are generally chronic conditions

Hypotension, tracheal deviation, and elevated jugular venous pressure indicates that a simple pneumothorax has progressed to what? What does CXR show for this?

a tension pneumothorax; lack of lung vascular markings at periphery

What are the criteria for diagnosing ARDS - acute respiratory distress syndrome? Mortality 40-60%

a. ratio of PaO2/FiO2 < or = 200 b. detection of bilateral pulmonary infiltrates on CXR c. pulmonary wedge pressure < or = 18mmHg or no clinical sign of elevated left atrial pressure

APAP causes hepatotoxicity through an intermediate metabolite when glutathione stores are depleted. Treatment with ___, ___, and supportive care is required when the level is 150mg/dL at 4 hours after ingestion.

activated charcoal and NAC - N-acetylcysteine

A 22-year-old patient with sickle cell disease presents to the emergency department complaining of chest pain, fever, and non-productive cough. On physical exam his temperature is 100.6˚F, BP is 144/88, pulse is 110, respiratory rate is 24, and pulse oximetry is 84%. CBC shows a WBC of 11,500, hemoglobin of 8.3%, and hematocrit of 28%. What is the most likely diagnosis? A Acute bronchitis B Acute chest syndrome C Asthma D Bronchiectasis E Pneumothorax

acute chest syndrome Patients with sickle cell disease are prone to acute chest syndrome, resulting from sickling of cells within the lung that typically presents with chest pain, tachypnea, cough, fever, and oxygen desaturation. Acute bronchitis (A) and bronchiectasis (D) typically present with a productive cough without significant oxygen desaturation and anemia. Patients with asthma (C) and spontaneous pneumothorax (E) will be afebrile and have normal hemoglobin and hematocrit.

A 54-year-old man with a history of chronic alcohol abuse presents to the emergency department with complaints of a subjective fever and severe epigastric pain radiating to the back. The pain has been present for the past 8 hours and is associated with nausea and vomiting, which has not relieved the pain. Laboratory data reveal a WBC of 14,000/mm 3 and a serum amylase of 500 U/L (reference range 0-286 U/L). Plain films of the abdomen were unremarkable. Which of the following is the most likely diagnosis? A Perforated duodenal ulcer B Acute cholecystitis C Acute pancreatitis D Mesenteric ischemia E Choledocholithiasis

acute pancreatitis C Acute pancreatitis typically presents with severe, steady midepigastric abdominal pain that radiates through to the back; pain is associated with fever, nausea, and vomiting. The most common causes of acute pancreatitis are gallstones and alcohol. Laboratory studies will show elevated WBC and serum amylase levels. Amylase elevations are nonspecific and can be elevated with perforated ulcers and mesenteric ischemia. A perforated ulcer will show evidence of free air on plain film; mesenteric ischemia will not present with fever or an elevated WBC unless there is the presence of infarcted bowel at which point the patient would appear septic. Acute cholecystitis may be associated with elevations in amylase but they are typically only a modest increase

A 24-year-old HIV-positive man comes to the emergency department complaining of severe left-sided chest discomfort, which radiates through to the left trapezius region. On coming into the room, you note that he is sitting up and hunched forward. On physical examination, the patient's blood pressure is 135/78, with a pulse of 85 bpm, and a pericardial friction rub is noted. Laboratory findings demonstrate elevated serum creatine kinase levels and normal serial troponin levels. His EKG demonstrates global ST segment elevation. His CXR demonstrates no acute process. Which of the following is the most likely diagnosis in this patient? A Acute pericarditis B Acute myocardial infarction C Acute bacterial endocarditis D Acute ascending aortic dissection E Acute costochondritis

acute pericarditis A Choice A is the most likely finding, as this patient is exhibiting signs, symptoms, and EKG findings pathognomonic for acute pericarditis, which is likely infectious in the setting of a patient with HIV. A pericardial friction rub is heard best with the patient in a seated position, during expiration, and is frequently found in patients with pericarditis. Choice B, an acute myocardial infarction, is less likely in a patient of this age, especially with normal serial troponins. Acute pericarditis can sometimes present with elevated serum creatine kinase levels when the epicardium is also involved. Choice C, acute bacterial endocarditis, is less likely in a patient with these EKG changes. Choice D, aortic dissection, would present with chest pain; however, the patient would be markedly hypotensive, less stable on presentation, and a CXR would demonstrate widening of the superior mediastinum

A 30-year-old man is brought to the emergency department by his wife for abdominal pain, nausea, vomiting, and diarrhea. She says he has been getting "worse and worse" for at least the past two months. He is "too tired" and his "muscles hurt too much" to play golf, formerly their favorite leisure activity. He has been depressed and reticent, instead of his usual talkative self. He won't eat much of anything, even when she cooks his favorite meals and she is sure he has lost considerable weight because his clothes "hang off him." He has refused medical evaluation until today, when the abdominal pain of approximately a week increased and he began having the vomiting and diarrhea. Initial impression is that the man is quite tanned, although it is the middle of winter. Closer examination reveals dark pigmentation in his skin folds and on the buccal mucosa. This presentation most strongly suggests which of the following? A adrenocortical insufficiency B diabetic ketoacidosis C hypercortisolism D hyperglycemic hyperosmolar state

adrenocortical insufficiency A This is a fairly classic presentation of adrenocortical insuffiency (Addison's disease). Diabetes mellitus, type 1, that has led to ketoacidosis (B) could also present with weight loss, nausea, and vomiting; but is also accompanied by hyperphagia and polydipsia, and does not have the hyperpigmentation associated with Addison's disease. Patients with hypercortisolism (Cushing Syndrome) (C) present with central obesity, hirsutism, thin skin, poor wound healing, and a host of other problems including emotional lability. Those with hyperglycemic hyperosmolar state (D) are typically older, have a high body mass index, and present with lethargy, confusion, and dehydration. Patients with hypothyroidism (E) usually have weight gain and constipation along with lethargy, fatigue, and weakness.

Epiglottitis MC b/w ages 2 and 6. What is the treatment of epiglottitis?

airway management w intubation or tracheostomy; oxygen; hydration; antibiotics (Ceftriaxone or Cefotaxime) ; steroids

Dilated Cardiomyopathy: most common cause is ____. Others?

alcohol; may also be idiopathic, myocarditis, or drugs (doxorubicin) -- 1 in 3 cases of heart failure are caused by dilated cardiomyopathy

Salicylates overdose causes a respiratory ____ and metabolic ____. Treatment of choice is ____along with activated charcoal, whole-bowel irrigation, and urinary alkalinization.

alkalosis; acidosis; hemodialysis; hemodialysis can also be used in methanol overdose

A 61-year-old man arrives at the emergency department (ED) suffering an acute myocardial infarction as a result of coronary artery thrombosis. One of the agents administered to the patient is a thrombolytic agent. From the choices below, which drug is a thrombolytic agent? A abciximab B alteplase C warfarin D heparin E clopidogrel

alteplase B Both warfarin and heparin are anticoagulants that are indicated for the prevention of thrombi. They do not actively lyse clots, but are capable of preventing further thrombogenesis. Both abciximab and clopidogrel are considered antiplatelet agents. Abciximab inhibits the activation of glycoprotein IIb/IIIa receptors on platelets, which helps to reduce platelet aggregation. Clopidogrel blocks adenosine diphosphate (ADP) receptors on platelets. The binding of ADP to these receptors is an important cellular mechanism in stimulating platelet aggregation. Alteplase converts plasminogen to plasmin, which then actively dissolves the fibrin threads associated with a thrombus.

Methanol is broken down into formic acid which may cause blindness. Etylene glycol causes profound metabolic acidosis and renal dysfunction. Treatment of both is centered around what?

antagonism of alcohol dehydrogenase w either ethanol or 4-MP and by dialysis

The classic CXR for _____demonstrates a widened mediastinum, hilar adenopathy, and the absence of a focal infiltrate.

anthrax

A 36-year-old male is brought to the emergency department in handcuffs, after he sustained a laceration to his left leg while trying to outrun the police. Apparently, he was driving a stolen car when he was pulled over for speeding. Upon talking with him, you learn that he has been in jail twice before for robbery. During the history and physical exam he appears callous and impulsive. What is the most appropriate classification for this personality disorder? A Antisocial B Avoidant C Narcissistic D Paranoid E Schizoid

antisocial A Antisocial personality disorder consists of clinical findings that include selfishness, callousness, promiscuousness, impulsive behavior, and an inability to learn from experience and legal problems. Avoidant personality disorder presents clinically as someone who fears rejection, overreacts failure, has poor social endeavors, and low self-esteem. Narcissistic personality disorder presents with the clinical findings of grandiosity, a preoccupation with power, lacking interest in others, and excessive demands for attention. Clinical findings of someone who has paranoid personality disorder would include defensiveness, being overly sensitive, secretive, suspicious, and hyper-alert, and having a limited emotional response. Clinical findings of schizoid personality disorder include being shy, introverted, withdrawn, and avoiding close relationships.

Traumatic rupture of thoracic aorta: If high clinical probability of aortic injury, ____should be done. Unstable patients with suspected aortic rupture should have a bedside ___. All other stable patients may undergo ____of the chest for evaluation of aortic rupture.

aortography; TEE (transesophageal echocardiogram); CT angiogram

With acute sinusitis, patient presents with sinus pressure or pain over infected sinus. Do not treat with antibiotics until how much time has passed? What is the drug of choice first line?

at least 7 days; Augmentin 1000/62.5 for 7-10 days.

A 55-year-old woman with a history of mitral stenosis, secondary to rheumatic heart disease, presents to the emergency department with increasing dyspnea while walking up one flight of stairs. She denies chest pain and discomfort, but states that recently she has also noticed palpitations. She also admits to lower extremity edema, which is new within the last week. Which of the following tachyarrhythmias is she most likely to demonstrate on EKG? A Ventricular tachycardia B Atrial flutter C Ventricular fibrillation D Ventricular bigeminy E Torsades de pointes

atrial flutter Choice B is correct. As patients with mitral stenosis age, and their mitral stenosis progresses to moderate or moderately severe mitral stenosis (most commonly after their fourth decade), the incidence of atrial arrhythmias—including premature atrial contractions, paroxysmal tachycardia, atrial flutter, and atrial fibrillation—increases. Choices A, C, D, and E are less likely, given that they are ventricular arrhythmias.

What are the treatments for bradyarrhythmias?

atropine, pacing, or epinephrine/dopamine

Shoulder dislocation commonly involves injury to which nerve? A Axillary B Median C Peroneal D Radial E Ulnar

axillary A The axillary nerve is in close proximity to the glenohumeral joint, thus making it vulnerable to injury during a shoulder dislocation. The median, radial, ulnar nerves are more distal in the upper extremity and and the peroneal nerve is in the leg.

How long should Plavix/Clopidogrel be used for bare metal or drug eluting stents?

bare metal - 30d-12m drug eluting - >/=12mon

Fusiform cerebral aneurysms are elongated dilations of large arteries usually associated with atherosclerosis. Where do they typically develop?

basilar artery

In a patient with possible placenta previa, why should vaginal examination not be performed?

because digital examination could trigger a hemorrhage

n 18-year-old female comes to the emergency room stating she was raped just a few hours ago. She is not otherwise harmed, but does admit to a history of physical abuse between the ages of six and eight at the hands of a family member. Given this history, you know she is at higher than average risk for post-traumatic stress syndrome. You care for her immediate medical needs and are ready to release her. In counseling her on next steps, which of the following is most critical in order to improve her prognosis? A Begin therapy as soon as possible B Begin treatment with a serotonin uptake inhibitor C Begin treatment with a beta blocker to reduce symptoms D Begin treatment with prazosin to prevent sleep disturbance

begin therapy as soon as possible A Therapy to aid in working through the traumatic experience (A), instituted as soon as possible after the event, has proven to be the most helpful way to avert or minimize post-traumatic stress disorder. This patient does not currently have any symptoms of PTSD, so pharmacologic treatment is not indicated. In a patient who is diagnosed with PTSD, SSRIs (B) may be helpful in reducing panic and improving sleep, beta-blockers (C) may reduce symptoms of anxiety, and prazosin (D) may help with sleep. Legal procedures (E) may help a patient in dealing with the event, but there are no data supporting this as a therapeutic intervention.

What two diagnostic tools are used to help rule out an ectopic pregnancy? What remains the gold standard for the diagnosis of ectopic pregnancy?

betaHcg & transvaginal ultrasound; Laporoscopy

A 48-year-old man presents to the emergency department with acute right upper quadrant tenderness, fever, and mild jaundice. Which of the following is most likely to be elevated in the blood? A bilirubin B creatinine C glucose D ketones E uric acid

bilirubin A This patient's signs and symptoms correlate with a suspected case of cholecystitis. Jaundice is associated with hyperbilirubinemia, in which the excess bilirubin can deposit in tissues such as the skin, sclera, and nails, causing a yellowish discoloration. Bilirubin is the waste product generated from the metabolism of hemoglobin.

Achalasia shows a classic ______ deformity on barium swallow. Treatment of achalasia can be done with a muscle relaxant like ____ or endoscopic injection of _______ toxin.

birds beak; nifedipine; botulinum

You are doing your usual morning rounds with your supervising physician when you are called to the emergency department with a new admission. In room 7 of the emergency department you note an ill-appearing 72-year-old male with a diagnosis of acute renal failure due to postrenal azotemia. Which of the following would be the most likely cause of his postrenal azotemia? A renal artery stenosis B nonsteroidal anti-inflammatory drug (NSAID) use C massive bleeding D dehydration E bladder outlet obstruction

bladder outlet obstruction E The correct answer is (E). Postrenal azotemia is caused by an obstructive process of the bladder, urethra, or ureters. In this case the patient is likely to have bladder outlet obstruction as a cause of his postrenal azotemia. In older med with benign prostatic hypertrophy (BPH), the patient may present with n/v, abdominal pain, and bladder distension. Relief of the obstruction should relieve the patient's symptoms and potentially the acute renal failure. All other choices are suggestive of prerenal azotemia.

What does CXR show with pleural effusion? What is the tx?

blunting of costophrenic angle - free pleural fluid on lateral decubitis film; thoracentesis

In ____, auscultation of the chest reveals fine rales or audible wheezing and a prolonged expiratory phase secondary to air trapping. CXR: hyperinflation, air trapping, peribronchial cuffing/thickening.

bronchiolitis

A 3 year-old boy is brought to the emergency department due to acute onset of cough and wheezing. Physical exam reveals focal wheezing in the right lower lobe. Which of the following is the most effective treatment option for the patient's suspected diagnosis? A Albuterol B Azithromycin C Bronchoscopy D Chest physiotherapy E Prednisone

bronchoscopy The patient has most likely aspirated a foreign body. The most effective treatment is removal of the foreign body through bronchoscopy (C). Supportive therapy includes bronchodilators for wheezing/airway obstruction (A), antibiotics for associated infections (B), and chest physiotherapy (D) to promote recovery after removal of the foreign body.

What type of troponin is tested for and why with MI? Is cTn a specific and sensitive test? What level must the maximum measured amount be above for positive troponin?

cTn (specifically cTnI) because it is released by myocardial filaments when they are injured. Yes, it is extremely reliable Rise and fall with serial testing with a *max above the 99th percentile*

Hypertrophic cardiomyopathy: is due to hypertrophy of the _____. PE reveals mitral regurgitation, a ____heart sound, and prominent left ventricular impulse. EKG reveals LVH

cardiac septum; S4

In a young patient with stroke symptoms and possibly recent neck trauma, what should be considered?

carotid dissection

A 78-year-old woman with a medical history of diabetes and hypertension presents to the emergency department complaining of left hand weakness and slurred speech. Which of the following tests is most likely to determine the source of an arterial thrombus? A carotid ultrasound B CT of the brain C erythrocyte sedimentation rate D magnetic resonance angiography (MRA) of the vertebral arteries

carotid u/s The patient's symptoms are consistent with pathology arising from the anterior cerebral circulation including the carotid arteries. A CT should be ordered to rule out acute hemorrhage and an erythrocyte sedimentation rate may be useful if giant cell arteritis were suspected. An MRA of the vertebral arteries would likely show deficits but is not likely to demonstrate the etiologic location of this stroke.

What nerve injury is associated with a sacral fracture?

cauda equina

A 62-year-old female with a known history of hypertension presents due to the abrupt onset of a severe headache, marked vertigo, nausea, vomiting, and ataxia. On physical exam, you note nystagmus, sensory loss, and weakness of the right face. What is the most likely diagnosis? A Cervical artery dissection B Cerebellar hemorrhage C Internal auditory artery occlusion D Lacunar infarction E Spinal cord compression

cerebellar hemorrhage A cerebellar hemorrhage can result from multiple causes, similar to other intracerebral hemorrhages, such as hypertension, blood dyscrasias, trauma, and arteriovenous malformations. Patient presentation may range from an abrupt onset of headache to full coma, depending on the severity of the hemorrhage. Presentation is often similar to cerebellar infarction, with CT findings assisting in the differentiation. Symptoms may include all of those listed above as well as nuchal pain, altered consciousness, altered respiratory rate, abnormal eye movements, and impaired papillary responses. Cervical artery dissection may present with similar symptoms, including the abrupt onset of headache, but is not typically associated with ataxia, vertigo, or vomiting. Internal auditory artery occlusion is associated with vertigo and unilateral hearing loss. Lacunar infarction occurs within small resistance vasculature, with motor and sensory symptoms related to the impacted brain region. Spinal cord compression may be acute or progressive, with motor weakness and sensory loss caudad to the lesion.

Treatment of acute symptomatic hyponatremia is with hypertonic saline (3%); what can happen if saline is given too rapidly?

cerebral edema or central pontine myelinolysis

CRAO: Meds such as timilol, acetazolamide, and mannitol may help to reduce intraocular pressure. What does the macula appear like on exam?

cherry red spot

How do we treat primary biliary cirrhosis?

cholesteramine for itching, ursodeoxycholic acid

An 8-year-old girl is brought in to the emergency department with abdominal cramps, nausea, and vomiting since early this morning. She has had two loose stools but denies melena or hematochezia. She has had a low-grade fever. In the past hour, her vision has become blurry and she feels increasingly weak. Her mother has had similar but milder symptoms. Twenty-four hour dietary recall includes only chicken broth today. Last night for dinner they had meatloaf (fully cooked), mashed potatoes, and green beans. Her mother cans all their vegetables. Her medical history is unremarkable. She takes no medications. No known drug allergies. Examination reveals a temperature of 99°F, clear lungs, and mildly tachycardic heart with no murmur audible. Abdomen-bowel sounds present, soft with mild diffuse tenderness, no guarding. Neurologic examination is significant for decreased visual acuity and decreased motor strength (2/5) in the upper and lower extremities. The most likely etiology is A enterotoxic E coli B cholera species C pinworms D Clostridium botulinum

clostridium botulinum Clostridium botulinum produces a neurotoxin that can lead to life-threatening illness including respiratory paralysis. Botulism infection is caused by the spore-forming bacteria that lives in soil and can be foodborne. In the latter case, home-canned foods are often the cause. After a 12-hour to 3-day incubation period, botulism begins with classic symptoms of abdominal pain, nausea, vomiting, and mild diarrhea and, if unchecked, evolves into a progressive neurologic disorder marked by double vision, motor weakness, and ptosis. Respiratory muscle involvement may occur ultimately and result in death. Because of the virulence of the neurotoxin it has been used as an agent of bioterrorism. Cholera and enterotoxigenic E. coli cause a foodborne diarrheal illness that can result in significant morbidity and mortality, but they do not have neurologic manifestations. Pinworm infection is usually found among younger children, is marked by severe anal itching, and fecal-oral transmission

A patient who is intoxicated presents to the emergency department. On ocular exam, you notice mydriasis. Which substance could he have been using? A sedatives B PCP C opioids D cocaine

cocaine Patients intoxicated with cocaine present with mydriasis. In opioid intoxication, the pupils are constricted. PCP intoxication is associated with nystagmus.

A 17-year-old male is brought to your Emergency Department by his girlfriend. She states that he has been behaving strangely for the last three days, with rapidly fluctuating moods ranging from euphoric to irritable and paranoid. The patient states that he is fine, just a little nervous about an upcoming test in school. His pulse is 126 beats per minute, BP 182/106, pupils are widely dilated, and he is diaphoretic. What is his most likely diagnosis? A Acute anxiety B Bipolar disorder C Cocaine intoxication D Heroin intoxication E Thyrotoxicosis

cocaine intoxication This patient's presentation with tachycardia, hypertension, diaphoresis, and mydriasis along with the behavioral changes is consistent with cocaine intoxication (C). His physical symptoms could be explained by thyrotoxicosis (E), but he has no history of hyperthyroid symptoms such as weight loss and it would not explain the mydriasis. Acute anxiety (A) or bipolar disorder (B) might explain some of the mood changes but would not account for all of his physical signs. Heroin withdrawal (D) would cause some similar symptoms, but intoxication would cause somnolence and pinpoint pupils.

CHF - Diastolic dysfunction means a problem with the ____.

compliance or relaxation of the heart during ventricular filling

Patients with branch retinal artery occlusion and central retinal vein occlusion present with what classic physical exam finding?

cotton wool spots

What is the treatment for retinal detachment to correct the tear?

cryotherapy or photocoagulation

Diving: The most common form of barotrauma occurs during _____ and is middle ear "squeeze" -- caused by inability to equalize pressure causing TM bleeding or rupture. Barotrauma during ____ is due to expansion of gas in body cavities.

descent, ascent

A 24-year-old man with a recent history of a viral illness comes to the emergency room complaining of severe left-sided chest discomfort, which radiates through to the left trapezius region. On coming into the room, you note that he is sitting up and hunched forward. On physical examination, the patient's temperature is 39°C, blood pressure is 135/78, with a pulse of 85 bpm, and a pericardial friction rub is noted. Laboratory findings demonstrate elevated serum creatine kinase levels and normal serial troponin levels. Which of the following would be the most likely electrocardiographic findings? A Diffuse ST segment elevation B Peaked T waves C Inferior Q waves D Loss of R-wave amplitude E U waves

diffuse ST segment elevations In a patient with these signs, symptoms, and lab findings, acute pericarditis is the most likely diagnosis. In patients with acute pericarditis, EKG changes occur secondary to inflammation of the subepicardium, leading to widespread elevation of the ST segments, often with upward concavity, which returns to normal after several days, followed by T wave inversion. No significant QRS complex changes are noted, so choice C, the development of inferior Q waves (frequently associated with an inferior myocardial infarction), is incorrect. Choice B is frequently noted with severe hyperkalemia. Loss of R-wave amplitude, choice D, is associated with myocardial infarction. Choice E, U waves, are associated with hypokalemia.

A 66-year-old male with a history of hypertension, diabetes mellitus, and hypercholesterolemia presents by emergency medical services (EMS) to the emergency department complaining of severe chest pain with radiation into his back. The patient states that he was feeling well in the morning, but while performing some light activity he felt a "ripping" sensation in his back, which he initially thought was a pulled muscle. The pain continued and the patient started to have chest pain, shortness of breath, and lightheadedness. On initial examination the patient is still in pain, pale, diaphoretic, and has a blood pressure of 85/40. His chest is clear to auscultation, and he has a 3/6 diastolic murmur best appreciated at the base of the heart. Given this clinical scenario, what is the most likely diagnosis? A Pneumothorax B Dissecting thoracic aneurysm C Acute myocardial infarction D Pulmonary embolus

dissecting thoracic aneurysm B This patient is exhibiting a history and physical examination that is consistent with a thoracic aneurysm. The patient's history of hypertension, along with the "ripping" sensation in his back and hypotension give a clinical presentation that is suggestive of a thoracic aneurysm dissection (B). A pneumothorax (A) would have more pleuritic characteristics, and chest pains without the ripping sensation or loud diastolic murmur would be more likely in a situation of myocardial infarction (C). Pulmonary embolus (D) and esophageal perforation (E) would typically not present with the above complaints or physical exam findings.

A 14-year-old boy presents to the emergency department with acute scrotal pain and vomiting for the past 2 hours. His left testicle is in extreme pain and he states the pain started while playing basketball in gym class. Which diagnostic test would help confirm your suspected diagnosis? A Transillumination B Doppler ultrasound C Urine cultures and sensitivity D Radionuclide imaging E Serum human chorionic gonadotropin levels

doppler u/s B Doppler ultrasound (B) is the diagnostic imaging of choice to confirm testicular torsion, with radionuclide imaging (D) a distant second. Testicular torsion is time sensitive and MRI or more invasive imaging may lead to the delay of surgical intervention. Time is critical (< 6 hours) for the salvage of the affected testicle. Transillumination (A) is seen in hydrocele fluid. Urine cultures and sensitivity (C) can confirm urinary tract infections or sexually transmitted diseases causing epididymitis. If an intrascrotal tumor is suspected, serum tumor beta-human chorionic gonadotropin levels (E) should be obtained.

In the emergency department, you are asked to evaluate a 77-year-old man with a history of HTN who had a syncopal episode while chasing after his dog. He admits to recent episodes of chest discomfort, also associated with activity, as well as dyspnea at lower levels of activity including walking up one flight of stairs. On physical exam, a grade III/IV crescendo-decrescendo systolic ejection murmur can be heard best over the right upper sternal border. His EKG demonstrates NSR @ 80 bpm, with evidence of left ventricular hypertrophy. His troponin levels are negative for ischemia. What is the next most appropriate test or procedure? A Echocardiography B VQ scan C CT scan of the head D Serum D-dimer levels

echo A This patient exhibits all the signs of progression of aortic stenosis, thus echocardiography is the next most appropriate test. A determination of severity can then be made, with possible cardiac catheterization if severe aortic stenosis is suspected, in preparation for surgical intervention if necessary. A VQ scan is appropriate if pulmonary embolism were suspected. A CT scan of the head could be considered if a head injury was suspected, but would not be the next step in the management of this patient. Serum D-dimer levels might be used to rule out pulmonary embolism, although it is a fairly nonspecific test. An MRI of the heart is not considered standard of care for aortic stenosis

What is the most common joint dislocation in children? A Ankle B Elbow C Finger D Knee E Shoulder

elbow In children the elbow is the most commonly dislocated joint and it is the third most common joint dislocation for adults. The shoulder and finger are dislocated more frequently than the elbow in adults. Knee dislocations at the femur-tibia joint are rare (patellofemoral dislocations are more common) and ankle dislocations are also relatively rare

A 55-year-old woman with a history of emphysema, who is undergoing chemotherapy for lung cancer, comes to the emergency department complaining of a sudden increase in dyspnea, with exertion and fatigue. On physical exam, hypotension, pulsus paradoxus, and muffled heart sounds are noted. On transthoracic echocardiography, cardiac tamponade is noted, with over 200 mL of pericardial fluid described. Which of the following would be this patient's most likely electrocardiographic finding (Figure 7)? A Torsades de pointes B U waves C Electrical alternans with sinus tachycardia D Peaked T waves E Convex elevation of the J point

electrical alternans C Choice C, electrical alternans with sinus tachycardia, a beat-to-beat alteration in one or more components of the ECG signal, is considered a specific sign of pericardial effusion, often with cardiac tamponade, as it represents the periodic swinging motion of the heart in the effusion at a frequency that is ½ the heart rate. Choice A, torsades de pointes, is a type of ventricular tachycardia frequently seen, and is associated with electrolyte disturbances or the use of certain types of antiarrhythmic drugs. Choice B, U waves, are associated with hypokalemia. Choice D is frequently noted with severe hyperkalemia. Choice E, convex elevation of the J point, is seen in patients suffering from hypothermia

In pericardial tamponade, the ECG may show ____as the heart swings within the accumulated pericardial fluid. What diagnostic tool helps identify pericardial tamponade?

electrical alternans; FAST exam

A 55-year-old woman with a history of emphysema, who is undergoing chemotherapy for lung cancer, comes to the emergency room complaining of a sudden increase in dyspnea, with exertion and fatigue. On physical exam, hypotension, pulsus paradoxus, and muffled heart sounds are noted. On transthoracic echocardiography, cardiac tamponade is noted with over 200 mL of pericardial fluid described. Which of the following is the most appropriate next step in management? A Enoxaparin 1 mg/kg subcutaneously Q 12 H B EKG C Cardiac catheterization D Penicillin V 500 mg PO BID x 10 days E Emergent pericardiocentesis

emergent pericardiocentesis E Choice E, emergent pericardiocentesis, should be considered when patients exhibit symptoms suggestive of severe cardiac tamponade, such as described above, with confirmatory echocardiographic findings of a large pericardial effusion, as this can be fatal if not treated promptly. Choice A is inappropriate, as this could lead to worsening of cardiac tamponade if it is secondary to bleeding into the pericardial space, such as with trauma or postoperatively. Choice B could provide additional confirmation of the diagnosis if a reduction in amplitude of QRS complexes is demonstrated, and electrical alternans of the P, QRS, and T waves, but would not provide any therapeutic benefit. Choice C could be the next appropriate step in management of myocardial infarction, but not in cardiac tamponade. Choice D represents appropriate therapy for patients with acute rheumatic fever, but not for patients with cardiac tamponade.

What is the tx for cauda equina syndrome?

emergent surgical decompression

With dysfunctional uterine bleeding, it is important to determine if ovulation has occurred. What is the gold standard to determine if ovulation is occurring?

endometrial biopsy

Patients with anaphylaxis should first have a patent airway. What medications are involved in treatment?

epinephrine; steroids to prevent late-phase reactions, and H1/H2 blockers ie. Benedryl and Ranitidine

A 67-year-old female presents to the emergency department with abdominal pain, bloating, inability to pass gas or stool, and vomiting. Which of the following, if present, would be a contraindication to placing a nasogastric tube? A Esophagitis B Esophageal strictures C Esophageal varices D Peptic ulcer disease E Gastroesophageal refulx disease

esophageal strictures Contraindications to nasogastric tube placement include choanal atresia, significant facial trauma, basilar skull fracture, esophageal stricture or atresia, esophageal burn, zenker's diverticulum, recent surgery on the esophagus or stomach, or a history of gastrectomy or bariatric surgery.

Vasopressin and octreotide, vasodilators, are used in severe cases of ________to constrict dilated vessels.

esophageal variceal bleeding

A 39-year-old man presents to the emergency department with massive hematemesis. His physical examination reveals slight jaundice, palmar erythema, spider angiomas, and marked ascites. Vitals at the time of presentation are as follows: BP: 85/44 mm Hg, P: 122/min, R: 16/min, oxygen saturation: 96%, and T: 99.8°F. Which of the following is the most likely cause of the massive hematemesis? A Peptic ulcer disease B Mallory-Weiss tear C Gastric carcinoma D Arteriovenous malformation E Esophageal varices

esophageal varices The most common cause of massive upper gastrointestinal bleeding in patients with cirrhosis is esophageal varices. Although 20% of patients with portal hypertension will have bleeding from other causes (peptic ulcer disease, Mallory-Weiss tears, or gastritis), endoscopic evaluation in patients with portal hypertension is necessary for diagnosis and initial therapy.

Blepharitis is inflammation of the anterior or posterior ____. Treatment is good hygiene and sulfonamide/antistaphylococcal eye ointment or systemic antibiotics.

eyelids

A 20-month-old boy is brought into the emergency department by his parents. They state he has not been feeling well for 2 days and this morning noted he was "shaking all over" and was not responding to commands. This went on for less than 10 minutes and has never happened before. His current rectal temperature is 100.7°F. The seizures are characteristic of A absence seizures B Lennox-Gastaut syndrome C febrile seizures D infantile spasms E juvenile myoclonic epilepsy

febrile sz Febrile seizures can occur in children younger than 5 years when accompanied by a fever. They are characterized by a brief generalized motor seizure. Absence seizures are generalized seizures characterized by a loss of consciousness without motor involvement, typically seen in older children. Lenox-Gastaut syndrome presents in childhood as well but is usually associated with developmental delay and seizures of akinetic and myoclonic nature (referred to as drop attacks). Infantile spasms occur without relation to systemic illness and are massive myoclonic events with bending at the waist. Juvenile myoclonic epilepsy evolves in the teenage years and is characterized by repeated episodes of myoclonic seizure activity.

A 88-year-old female is found lying on the ground in a supine position after sustaining a fall in her house from tripping on the rug.. Her leg is shortened, abducted and externally rotated, and she is complaining of pain to the right leg with radiation to the knee. Based on the history of the patient, what type of injury has this patient sustained? A Non-displaced pelvic fracture B Hip dislocation C Femoral shaft fracture D Femoral neck fracture E Distal femur fracture

femoral neck fracture When a fracture occurs in the femoral neck that includes displacement, the leg appears shortened, abducted and externally rotated. The tension that exists from muscles attached above and below the fracture site results in shortening of leg length after the fracture as the muscles contract. If there is no displacement of the bone, no leg length changes should occur. Generally, hip fractures would not result in a lengthening of the leg, so all answers that include this option would be wrong. When the leg appears shortened, flexed, adducted, and internally rotated, a posterior hip dislocation should be suspected. A leg that is flexed, abducted and externally rotated suggests an anterior hip dislocation. Posterior hip dislocations are far more common than anterior dislocations, accounting for more than 90% of all hip dislocations.

A 4 year-old male presents to the emergency department with vomiting, severe abdominal pain, and diarrhea that occurred 2 hours after "getting candy from Grandma's purse". Which of the following medications did the child most likely ingest? A Cisplatin B Erythropoietin C Ferrous sulfate D Lisinopril E Vincristine

ferrous sulfate Stage 1 of iron toxicity secondary to ferrous sulfate ingestion (C) is characterized by acute GI irritation; this is followed by a latent phase (Stage 2) that can then progress to systemic iron toxicity (Stage 3), that can progress to hepatic failure (Stage 4) or delayed sequelae (Stage 5). Cisplatin (A), erythropoietin (B), and vincristine (E) are parenterally administered and unlikely to be present in a patient's purse. Lisinopril (D) toxicity consists of cardiovascular symptomatology (e.g., hypotension and tachycardia).

Anthrax and Yersinia pestis plague are treated with ___or___.

fluoroquinolones or tetracyclines

Malignant hypertension bp? What is the rule of thumb for lowering?

greater than 220/140; 10% in first hour and 15% for the next 3-12 hours, to normal over next 2 days

In a boxer's fracture, the presence of how much angulation of the fifth metacarpal neck would require referral for reduction as opposed to treatment with a simple ulnar gutter splint? A Less than 10 degrees B 10-19 degrees C 20-29 degrees D 30-39 degrees E Greater than 40 degrees

greater than 40 degrees When there is greater than 40 degrees of angulation or an extensor lag (the patient cannot fully extend the affected finger) then a referral is required. Lesser degrees of angulation without an extensor lag can generally be handled conservatively with an ulnar gutter

A 25-year-old male has a history of schizophrenia, and was brought to the emergency department by ambulance after he was found wandering along the highway. Which of the following is considered a positive symptom of schizophrenia? A Catatonia B Diminished sociability C Hallucinations D Poverty of speech E Restricted affect

hallucinations C Hallucinations, delusions, and formal thought disorders are classified as positive symptoms of schizophrenia. Negative symptoms of schizophrenia include restricted affect, diminished sociability, and poverty of speech. Catatonia describes a state in which a person is withdrawn and shows minimal bodily movement, or one in which there is severe excitement and the person shows purposeless and stereotyped movements.

What laboratory value is depressed in all hemolytic disorders? What test is absolutely critical to evaluating hemolytic anemia?

haptoglobin (normal plasma protein that binds and clears hemoglobin released into plasma); peripheral blood smear or The Coombs test

A 64-year-old man has been experiencing signs and symptoms compatible with diverticular disease for the past 3 weeks. He now presents to the emergency department malnourished with severe left-sided lower abdominal pain. After appropriate workup and hydration, he is taken to the operating room where a perforated sigmoid colon is discovered with gross contamination. What is the most appropriate surgical intervention at this time? A Left colectomy with primary anastomosis B Hartmann procedure C Proctocolectomy D Abdominoperineal resection E Low anterior resection

hartmann procedure This vignette is consistent with an emergent resection in an unprepared patient. The most appropriate therapy for an acute perforation is a Hartmann procedure, which includes resection of the affected portion of the bowel, a temporary diverting colostomy, and oversewing of the distal rectal stump; the second stage of the procedure will involve taking down the colostomy with anastomosis to the rectal stump. A colectomy with a primary anastomosis should not be done when the bowel is unprepared due to the significant risk of infection and leakage of the bowel at the site of the anastomosis. Abdominoperineal resection is used in the treatment of malignant disease of the lower rectum. In this procedure, a permanent colostomy is created and the entire rectum, anal canal, and anus are removed. In the management of benign disease of the lower rectum, a proctocolectomy is appropriate to preserve anal function.

What is the rule of 9's for estimating the size of burns?

head = 9% each arm = 9% each leg = 9% front torso = 18% back torso = 18%

Baseline fetal _____ is between 110 and 160 beats/minute.

heart rate

For severe barbiturate toxicity, ____may be indicated but is ineffective for benzodiazepines. ____may be used to revere acute benzodiazepine overdose in patients without risk of seizure of benzodiazepine withdrawal.

hemodialysis; Flumazenil

What causes pseudohyperkalemia?

hemolysis after blood draws

The ____anemias occur from premature destruction of the RBCs in the reticuloendothelial system (extrinsic) or in the blood vessels (intrinsic ). Name some examples of intrinsic and extrinsic factors.

hemolytic Intrinsic: sickle cell, G6PD deficiency Extrinsic: immune, infection, hypersplenism

What is the emergent treatment for arterial embolism/thrombosis (pain, pallor, pulselessness, paresthesias, paralysis)?

heparin, emergency embolectomy-thrombectomy to restore blood flow

A 76-year-old man with a history of three myocardial infarctions, CABG x 4, COPD, HTN, and hyperlipidemia presents to the emergency department with complaints of increasing dyspnea with exertion. He now has to sit in his recliner to sleep. He complains of lower extremity edema, now above the knees. On physical examination, he exhibits jugular venous distention to the angle of the jaw at 90 degrees of truncal elevation, diffuse bilateral rales on auscultation of the lung, and a blowing systolic murmur that is heard best at the left lower sternal border. Which abdominal physical exam finding would be most likely given this patient's history? A Periumbilical ecchymoses B Murphy's sign C Tenderness at McBurney's point D Hepatomegaly E Absent bowel sounds

hepatomegaly D Choice D is correct, as the patient is demonstrating signs and symptoms of congestive heart failure, which can lead to hepatic congestion and hepatomegaly. Choice A, periumbilical ecchymoses, or Cullen's sign, are representative of hemoperitoneum. Choice B, Murphy's sign, is indicative of cholecystitis. Choice C, tenderness at McBurney's point, is frequently seen with appendicitis. Choice E, absent bowel sounds, is seen in patients with ileus.

What does the lab testing show in an asthmatic patient?

high WBC with eosinophilia Sputum shows --- Curschmann's spirals (mucous casts of small airways) Charcot-Leyden crystals

What is the primary treatment for pregnancy induced hypertension?

hydralazine

A 76-year-old man, is brought to the emergency department by his niece after she found him wandering around his yard in the cold wearing only a tee shirt and jeans. When she set up his pill container about 36 hours earlier, he seemed his usual self but, in retrospect, possibly a little more confused than usual. The niece says that he has "high blood," treated with a "white fluid pill," "sugar diabetes," treated with an oral medication, and early "old timer's" dementia treated with "a memory pill." Vital signs include an oral temperature of 100.8F, pulse 100 beats per minute, respirations 24 and somewhat shallow, and blood pressure of 88/52. Initial examination reveals a slightly dehydrated, stuporous man appearing older than his stated age, who smells strongly of urine. He has no lateralizing signs. What is the most likely cause of the mental status changes? A hyperglycemic hyperosmolar state B lactic acidosis C stroke D urinary tract infection E worsening dementia

hyperglycemic hyperosmolar state The combination of confusion and dehydration in a patient with diabetes type 2 who is taking a diuretic strongly suggest hyperosmolar state. Patients with lactic acidosis (B) have marked hyperventilation and, usually, signs and symptoms of a serious illness. The lack of lateralizing signs makes a stroke (C) less likely. Urinary tract infection (D) could certainly cause confusion and incontinence in an elderly man and should be investigated. Alzheimer dementia (E) progresses slowly; sudden decompensation is usually due to delirium.

A 63-year-old male with chronic kidney disease is in the ICU with bradycardia, flaccid paralysis, and an ileus. A stat work-up includes an ECG showing peaked T waves. Which lab finding would you suspect? A Hypomagnesemia B Hypercalcemia C Hypokalemia D Hypocalcemia E Hyperkalemia

hyperkalemia E Hyperkalemia (E), >5.0 mEq/L, usually occurs in patients with advanced kidney disease and impairs neuromuscular transmission including muscle weakness, flaccid paralysis, and ileus. ECG includes bradycardia, prolonged PR interval, peaked T waves, and QRS widening. Hypokalemia (C) can also present with flaccid paralysis or ileus but ECG findings show decreased and broadening T waves with prominent U waves. Hypomagnesemia (A) and hypocalcemia (D) have common symptoms of weakness and muscle cramps and can show prolonged QT intervals of ECG. Hypercalcemia (B) is often asymptomatic until >12 mg/dL, which includes constipation, polyuria, and nausea/vomiting, with ECG showing a shortened QT interval.

Pulmonary ____occurs when resistance to flow across the pulmonary vasculature increases. - may see prominent upper lobe pulmonary veins, increased density in the central lung fields, and Kerley B lines.

hypertension

A 15-year-old boy suddenly collapses on the basketball court; his sports physical conducted at the beginning of the year did not elicit any abnormal findings. Basic life support initiated at the scene, however, is unsuccessful in resuscitation. Which of the following is the most likely etiology of his sudden death? A mitral valve prolapse B surgically corrected aortic stenosis C hypertrophic cardiomyopathy D rheumatic heart disease

hypertrophic cardiomyopathy C Hypertrophic cardiomyopathy in adolescence is typically due to familial hypertrophic cardiomyopathy with an incidence of 1:500. Many patients are asymptomatic until a sporting event, which may cause symptoms, specifically sudden cardiac death. Examination may demonstrate a palpable or audible S 4 , an LV (left ventricular) heave, systolic ejection murmur (may need to stimulate cardiac activity), and/or a left precordial bulge. Echocardiography is the gold standard for diagnosis but family history should be assessed. Stress testing is indicated to assess for ischemia and arrhythmias. Strenuous activities are prohibited for these patients. The other cardiomyopathies (dilated and restrictive) are next but are not as common. Congenital structural abnormalities of the coronary arteries are the next most common cause. Valvular disorders, including surgically repaired aortic stenosis, are typically not causes of sudden death, but these patients should be screened for symptoms and stress tested as necessary.

Patients with adrenal crisis should be treated with IV glucose, saline, and hydrocortisone. What are the laboratory findings in adrenal insufficiency with sodium, potassium, and glucose?

hyponatremia; hyperkalemia; and hypoglycemia

What is the hallmark sign of cardiogenic shock?

hypotension

What is the most common clinical finding on vital signs in a patient with cardiogenic shock? A Fever B Hypertension C Hypotension D Tachypnea E Bradycardia

hypotension Hypoperfusion to the body is what generally causes the end organ failure associated with shock. The patient may also be tachycardic, but may not have fever or an increased respiratory rate as part of the abnormality. In most cases patients will have tachycardia unless they suffer a significant pump failure, which may cause bradycardia.

How do patients with tension pneumothorax present?

hypotension, distended neck veins, absent breath sounds over affected hemithorax, tracheal deviation

Hypotonic hyponatremia is divided into three categories ie. hypovolemic, isovolemic, or hypervolemic. Give examples of each type.

hypovolemic -- GI losses, excessive sweating isovolemic -- SIADH hypervolemic -- CHF, cirrhosis, renal failure

Secondary hypertension is HTN due to an ______.

identifiable cause ie. renovascular disease, coarctation of the aorta, primary aldosteronism, Cushing's, Pheochromocytoma, OSA, renal parenchymal hypertension

A ____hernia cannot be reduced and a ____hernia occurs when bowel edema compromises the blood flow to an incarcerated hernia. Both can give rise to a small bowel obstruction.

incarcerated; strangulated

Bladder -- the four type of ______are total, stress, urge, and overflow.

incontinence

Low calcium stimulates PTH release then VitD release and then what? High calcium causes PTH decrease then Calcitonin release and then what?

increased absorption to bone; enhances bone deposition and renal excretion of calcium

No nitroglycerin in which kind of MI?

inferior

What three things causing potassium to shift into cells? What are the EKG findings associated with hypokalemia?

insulin; alkalosis; and B-adrenergic agonists EKG: U waves, T-wave flattening or inversion, ST-segment depression

A 2-year-old baby girl is brought to the ED with a history of abdominal pain and diarrhea. Mother states that the child was playing normally and then "doubled over" with what appears to be abdominal pain. The abdomen appears slightly distended and is tender to palpation. While in the ED the child has a bloody, diarrheal bowel movement. Which of the following is the most likely diagnosis? A pyloric stenosis B mesenteric ischemia C Crohn disease D intussusception E Hirschsprung disease

intussusception D Intussusception is the most frequent cause of intestinal obstruction in the first 2 years of life. The patient develops paroxysms of pain followed by bloody bowel movements. Pyloric stenosis typically presents prior to the age of 6 months with vomiting but not with diarrhea. Hirschsprung disease results from an absence of ganglion cells in the colon and typically presents early in life with failure to pass meconium, followed by vomiting and abdominal distension. The typical age of onset is later in adolescence in Crohn disease and in the elderly in mesenteric ischemia.

Cardiology

is fun!

What is the treatment for septic arthritis?

joint drainage, systemic antibiotics for 3-4 weeks.

An avulsion fracture at the base of the fifth metatarsal is commonly called which of the following? A Bennett fracture B Boxer's fracture C Chauffer's fracture D Jones fracture E Lisfranc fracture

jones fracture An avulsion fracture at the base of the fifth metatarsal, usually secondary to plantar flexion and inversion is called a Jones fracture. Also called a ballet or dancer's fracture, it is the most common metatarsal fracture. The fracture occurs at the proximal diaphysis. A Bennett fracture is an oblique fracture of the first metacarpal near the carpometacarpal joint. A boxer's fracture is a fracture of the fifth metacarpal. This is the most common fracture of the hand. A chauffer's fracture is an oblique fracture through the base of the radial styloid in the forearm. A Lisfranc fracture is actually a fracture and dislocation involving the tarsometatarsal joints

ST Elevations in I, aVL, V4, V5, V6

lateral wall MI, left circumflex artery

What is the most common cause of pleural effusions?

left sided heart failure (increased hydrostatic pressure in microcirculation) ALSO - 1. decreased oncotic pressure - hypoalbuminemia 2. decreased pressure in pleural space - collapsed lung 3. increased permeability - in pneumonia 4. impaired lymphatic drainage - in malignancy 5. movement of fluid from peritoneal space - in ascites

In Guillain-Barre, what is the typical direction of weakness on the body?

legs then ascending pattern up the body ascending symmetric weakness or paralysis and loss of deep tendon reflexes - CSF, high protein and normal cell count

What O2 saturation level indicates O2 supplementation should be considered?

less than 95%

What types of connective tissue are injured in a sprain? A Bones and muscles B Fascia and joint capsules C Ligaments and joint capsules D Muscles and tendons E Tendons and bones

ligaments and capsules A sprain involves injury to those tissues that give support to joints - ligaments and joint capsules. Injury to muscles, tendons, and fascia would all be classified as a strain. Injuries to bone would be classified as a fracture.

Pneumonia CXR findings and associated bacteria: 1. Strep Pneumo, H Flu, and Klebsiella have ____consolidations. 2. Staph Aureus, Legionella, and Mycoplasma appear ___. 3. Pneumocystitis jiroveci is common in AIDS patients and appears _____.

lobar; patchy; diffuse interstitial and alveolar infiltrates

A 35-year-old man is brought to the emergency department with unremitting, generalized convulsive status epilepticus. The initial, preferred treatment is intravenous administration of which of the following? A phenobarbital B valproate C phenytoin D lorazepam E donepezil

lorazepam D In most patients suffering from generalized convulsive status epilepticus (GCSE), benzodiazepines such as lorazepam and diazepam are effective initial therapies due to their relatively high lipid solubility. As a result, they are able to cross the blood-brain barrier easily, which gives them the potential to stop seizures quickly. Lorazepam's lipid solubility is less compared to diazepam, and it also redistributes to fat more slowly. Hence, lorazepam tends to have a longer duration of action (12 to 24 hours) than diazepam (20 to 30 minutes). Phenytoin is often administered immediately after benzodiazepine administration for long-term seizure control, as it has a long half-life (20 to 36 hours) compared to diazepam. Phenytoin is not given first because its lipid solubility is less than the benzodiazepines and therefore cannot enter the brain quickly enough to terminate seizure activity.

Antibiotic treatment for Pertussis is a ____or Bactrim as a alternative.

macrolide - erythromycin, azithromycin, clarithromycin -- avoid erythromycin in infants <1 due to infantile hypertrophic pyloric stenosis

A 21-year-old male presents to the emergency department due to vomiting blood. He is a college student and was initiated into a fraternity earlier in the week, and admits to drinking enough alcohol to make him vomit that night. There was no blood in the vomit at that time. The hematemesis started today, about 20 minutes after he finished a workout at the gym. He notes that today was a particularly tough workout, as he increased the amount of weight he was lifting significantly compared to previous workouts. His vital signs are as follows: heart rate 86 bpm, respirations 14, BP 126/82, temp 98.8°F. What is his most likely diagnosis? A Mallory-Weiss syndrome B Peptic ulcer disease C Arteriovenous malformation D Esophageal varices E Erosive gastritis

mallory weiss syndrome A The correct answer is Mallory-Weiss syndrome. This is characterized by a nonpenetrating mucosal tear at the gastroesophageal junction, which may arise from a sudden increase in transabdominal pressure, such as lifting, retching, or vomiting. Peptic ulcer disease usually presents with a history of dyspepsia. Arteriovenous malformations usually present with melena or hematochezia. Esophageal varices usually develop secondary to portal hypertension, and are most often found in patients with cirrhosis. Erosive gastritis is often due to NSAIDs, alcohol, or severe medical or surgical illness, and is more often associated with chronic blood loss.

An elderly patient is brought in to the emergency department (ED) complaining of incontinence of liquid "like tea water" stool. He is complaining of rectal pressure and lower abdominal pain. The pain is cramping in quality and the patient's abdomen is "bloated." Digital rectal exam reveals hard stool in the rectum. Which of the following should be selected as the initial treatment for this patient? A passing a nasogastric tube B milk of magnesia C opiate analgesics for pain D oral sodium phosphate E manual disimpaction

manual disimpaction Mechanical bowel obstruction in the rectum does not usually respond to oral laxatives. A nasogastric tube would not be used for an obstruction in the distal colon/rectum. One would avoid opiates in fecal impactions and other constipation problems because they tend to be more constipating. This patient needs to be disimpacted. Oral agents are unlikely to be effective against the fecal impaction and may cause complications.

Bethesda inhibitor assay is for...

measuring the amount of antibody against factors in Hemophilia A and B

What is the most common radiologic finding in a patient with a tension pneumothorax? A Pleural effusion B Infiltrate C Enlarged cardiac silhouette D Elevated diaphragm E Mediastinal shift

mediastinal shift E Collapse of the lung, followed by an increase in intrapleural pressure, will lead to a tension pneumothorax. In most cases, the air leaks through the subcutaneous spaces. But in a tension pneumothorax, the air is locked in and creates a life-threatening emergency.

What is the treatment for mild and more severe bronchiolitis/RSV?

mild - albuterol, racemic epinephrine more severe - add IV hydration, ribavirin, RSV-IG prophylaxis Steroids not beneficial

Patients with pericardial tamponade present with Beck's triad. What is that?

muffled heart sounds distended neck veins hypotension

What is the classic arrhythmia associated with COPD?

multifocal atrial tachycardia

With croup, protect airway first! What does less severe treatment of croup involve?

nebulized saline, racemic epinephrine, and steroids if patient has stridor at rest.

What is the hallmark s/s of heat stroke?

neurologic dysfunction - frequently associated with cerebral edema

What is the agent of choice for BP lowering for patients with hypertensive encephalopathy, intracranial bleeding, and heart failure? Use with what for dissecting aneurysm?

nitroprusside; propranolol -- clonidine can also be used but sedation is common

Macular degeneration can be non-exudative (dry) or exudative (wet). There is no way to prevent which type? What is the treatment for the other type if neovascularization is present?

non-exudative (dry); laser photocoagulation

What is the imaging study of choice for kidney stones? Stones less than ____mm have a 90% chance of passing spontaneously.

noncontrast helical CT; 4mm

Your patient is a 14-year-old female, 5'4" weighing 80 pounds. Her menstrual cycle started at age 10 but stopped one year ago when she became concerned about her weight and began focusing on diet and exercise. Her mother brings her to the emergency room, stating she will only eat salads and runs 2 hours daily. What is the first consideration in the management of this patient? A Behavioral modification B Family therapy C Individual psychotherapy D Nutritional restoration E Pharmacologic intervention

nutritional restoration Nutritional deficiencies (D) such as dehydration and electrolyte imbalances must be urgently corrected. After metabolic imbalances have been addressed, a comprehensive, inter-disciplinary approach is optimal, with the primary goal of weight restoration. Behavioral, family, and individual therapies (A, B, and C) should all be a part of the longer-term management plan, and pharmacological therapy (E) may also be helpful.

A 16-year-old male was hit on the left side of his face by a line drive baseball. Marked swelling is noted externally to the left eye. There was no loss of consciousness. Upon physical exam, he complains of diplopia during extraocular motion testing. Enophthalmos is noted, as well as decreased sensation of the left cheek. Plain x-rays of the face demonstrate an air-fluid level in the left maxillary sinus, and a fracture of the orbit. Based on this information, what is the most likely diagnosis? A Zygomatic arch fracture B Orbital blowout fracture C Le Fort I fracture D Le Fort II fracture E Le Fort III fracture

orbital blow out fracture B Diplopia is common in an orbital blow out fracture, due to entrapment of the inferior rectus and inferior oblique muscles. Loss of infraorbital sensation occurs from disruption or swelling of the infraorbital nerve. A Le Fort I fracture describes a transverse fracture separating the body of the maxilla from the pterygoid plate and nasal septum. A Le Fort II fracture describes a pyramidal through the central maxilla and hard palate. Movement of the hard palate and nose occurs, but not the eyes. A Le Fort III fracture describes a craniofacial disjunction, wherein the entire face is separated from the skull due to fractures of the frontozygomatic suture line, across the orbit and through the base of the nose, and ethmoids. The entire face shifts, with the globes held in place only by the optic nerve.

Periorbital and orbital cellulitis: reports of visual changes and ocular pain is more indicative of _____. What is the imaging modality of choice? What is the treatment?

orbital cellulitis; orbital CT; 2nd or 3rd generation cephalosporin + vancomycin

A 33-year-old IV drug user presents to the emergency department with chills, diaphoresis, anorexia, and malaise. On physical exam, her temperature is 40°C, BP 98/55, P 115 bpm, and RR 22. Two separate blood cultures are positive for S.aureus. Which of the following physical exam findings would confirm a clinical diagnosis of infective endocarditis, according to the Duke criteria? A Increase in valvular regurgitation B Irregularly irregularly pulse C Osler's nodes D Buccal hemmorhages E Koplik spots

osler's nodes Choice C, Osler's nodes, confirms the clinical diagnosis of infective endocarditis, as it is a minor criteria. The Duke criteria for the clinical diagnosis of infective endocarditis requires the documentation of two major criteria, or one major criteria and three minor criteria, or five minor criteria. The patient demonstrates the presence of one major criteria (two separate blood cultures with typical microorganisms for infective endocarditis) and two minor criteria (fever greater than 38.0°C and predisposing condition of IV drug use). Only a new valvular regurgitation, not an increase or change in preexisting murmur, is considered sufficient to qualify as a major criteria, so choice A is incorrect. An irregularly irregular pulse, choice B, is commonly seen in patients with atrial fibrillation, not with infective endocarditis. Choice D, conjunctival hemorrhages, not buccal hemorrhages, are one of the minor criteria. Choice E, Koplik spots, are buccal lesions seen in patients infected with measles, whereas the presence of Roth's spots does fulfill one of the minor criteria.

Which of the following is a type of primary malignant tumor of the bone? A Enchondroma B Leiomyoma C Lipoma D Melanoma E Osteosarcoma

osteosarcoma E Osteosarcoma is a type of primary bone cancer. Fortunately this is a rare cancer, accounting for only 1% of the cancers diagnosed each year in the USA for patients of all ages. Osteosarcomas are more common in the pediatric population, accounting for 5% of all childhood cancers and 56% of all cancers of the bone in patients less than 20 years old. Osteosarcomas have a bimodal occurrence rate with the highest prevalence between ages 11-13 and over the age of 65. Enchondromas are common benign cartilaginous tumors that develop in the medulla (marrow cavity) of bone. A leiomyoma is another name for a benign uterine fibroid. A lipoma is a benign, soft, freely movable, generally nontender mass in the soft tissue sometimes referred to as a fatty tumor. These are generally inconsequential, but may be a marker for spina bifida if found in the lumbar region. Melanoma can be found in bone, but it would be considered a metastatic lesion and not a primary malignant bone tumor.

You are evaluating a 72-year-old male who is referred to the emergency department from his primary care office. On examination you note a lethargic obese male with the following vitals: BP of 225/135 a P of 88, and T of 98.4˚F. He reports discontinuing all his medications for blood pressure 6 months ago due to financial reasons. Which of the following physical examination findings would be most consistent with a diagnosis of a hypertensive emergency? A normal exam B xanthelasma C varicose veins D papilledema

papilledema D The correct answer is (D). This patient has significantly elevated blood pressure, lethargy, and evidence of hypertensive encephalopathy, which is supported by a physical examination finding of papilledema. Additional workup may be indicated to rule out other causes of his papilledema. Target organ damage is apparent in anyone with hypertensive emergencies and may be neurological, renovascular, cardiovascular, or a combination thereof. Prompt treatment is necessary to prevent complications. Although the physical examination may be normal, evidence of end-organ damage is likely on examination and/or laboratory/diagnostic studies. Choices (B), (C), (E) are not representative of end-organ damage seen in hypertensive emergencies.

Most common cause of anaphylactic shock?

parenteral administration of allergen

A 17-year-old female distance runner with no significant PMH complains that she has diffuse, aching anterior knee pain that is worsened when she walks up or down stairs or when she squats down. There has been no acute trauma, but she has been increasing her running mileage. No effusion is present. What is the probable diagnosis? A Anterior cruciate ligament tear B Medial meniscal tear C Osteoarthritis of the knee joint D Patellofemoral syndrome

patellofemoral syndrome D Patellofemoral syndrome is a common condition in active adolescents due to repetitive stresses on the patellofemoral joint. This can be exacerbated by altered patellofemoral tracking due to growth and development in adolescents. Other biomechanical issues that may contribute to this problem include poor flexibility, weakness of the vastus medialis muscle, which results in a more lateral tracking of the patella, and excessive foot pronation. This condition does not produce an effusion. Anterior and posterior ligament tears would be highly unlikely given that there was no history of an acutely traumatic event and because ligaments are fairly vascular structures, an effusion would be expected with any cruciate ligament tear. Meniscal tears in a young patient are generally associated with a traumatic twisting event and while not as vascular as a ligament, meniscal tears generally lead to the gradual development of an effusion. Older patients may experience a degenerative tear with minimal trauma, but that is unlikely in our 17-year-old patient. Osteoarthritis is generally associated with gradual wear and tear after many years or the process can be accelerated after a significant acute trauma to a joint. Neither scenario is applicable to this patient.

What are the classic EKG findings in hyperkalemia? Stabilize the cardiac membrane with what? Remove potassium with Kayexalate or furosemide. Shift potassium into cells with insulin/glucose, sodium bicarb, and albuterol

peaked T waves, prolonged PR, loss of P waves, widening QRS; calcium chloride or calcium gluconate

A 24-year-old HIV-positive man comes to the emergency department complaining of severe left-sided chest discomfort, which radiates through to the left trapezius region. On coming into the room, you note that he is sitting up and hunched forward. On physical examination, the patient's blood pressure is 135/78, with a pulse of 85 bpm, and a pericardial friction rub is noted. Laboratory findings demonstrate elevated serum creatine kinase levels and normal serial troponin levels. His EKG demonstrates peaked T waves. His CXR demonstrates a "water bottle" cardiac silhouette. Which of the following are serious consequences of acute pericarditis, which require careful monitoring? A Pericardial effusion B Aortic dissection C Myxedema D Chylopericardium E Acute myocardial infarction

pericardial effusion A Choice A, pericardial effusion, is a serious consequence of acute pericarditis, which requires careful monitoring to ensure that progression of the pericardial effusion does not lead to cardiac tamponade, which can be fatal if not treated promptly. Choice B is unlikely in a patient with acute pericarditis. Choices C, D, and E are noninfectious causes, not consequences of pericarditis.

A 24-year-old HIV-positive man comes to the emergency department complaining of severe left-sided chest discomfort, which radiates through to the left trapezius region. On coming into the room, you note that he is sitting up and hunched forward. Prior to examining him, you have reviewed his chart. Laboratory findings demonstrate troponins x 3, which are negative for myocardial ischemia. His EKG demonstrates diffuse ST segment elevations throughout. Which of the following physical exam findings would be most likely in this patient? A Roth spots B Splenic enlargement C Janeway lesions D Pericardial friction rub E Splinter hemorrhages

pericardial friction rub D Choice D is the most likely finding, as this patient is exhibiting signs, symptoms, and EKG findings pathognomonic for acute pericarditis, which is likely infectious in the setting of a patient with HIV. A pericardial friction rub is heard best with the patient in a seated position, during expiration, and is frequently found in patients with pericarditis. Choice A B, C, and E are physical exam findings seen in acute bacterial endocarditis

What is the treatment for constrictive pericarditis?

pericardiectomy --- otherwise NSAIDs and Steroids

A ______presents with asymmetric swelling of peritonsillar soft tissue and deviation of the uvula AWAY from affected side -- CP: sore throat, drooling, hot potatoe voice, trismus.

peritonsillar abscess

An 89-year-old female was found to have had an episode of syncope while at home. There was no history prior to the event, and the patient denies any chest pain prior to the episode occurring. On exam, the patient is alert, awake, and oriented, and is only complaining of mild shortness of breath. Her ECG is as shown. Which of the following is the best choice for treating this patient? EKG shows 3rd degree AV block. A No treatment B Permanent pacemaker C Digitalis therapy D Ablation therapy E Beta blockers

permanent pacemaker This patient has a third-degree AV block that is symptomatic, with syncope and mild shortness of breath. The treatment for this patient is pacemaker insertion. Immediate insertion depends on the vital signs of the patient. If the patient's vital signs are stable, a transdermal pacer can be used until a scheduled pacer insertion within 24 hours. If the vital signs are not stable, immediate intervention with either central venous pacing wires or an immediate pacer insertion is warranted.

What nerve injury is associated with a femoral shaft or lateral tibial plateau fracture?

peroneal nerve

Because ___is capable of causing hypersalivation, AV block, asystole, and seizures, its use is limited to severely ill patients whose diagnosis of anticholinergic intoxication is certain.

physostigmine

How is osteomyelitis diagnosed? Lab findings? What is the treatment for osteomyelitis?

plain x-ray, WBC is normal, possibly anemia of chronic disease, elevated sed rate, IV antibiotics or antifungals for 4-6 weeks

A 53-year-old man presents to the emergency department because of fever, headache, and confusion. On physical examination, you note an obtunded man who appears acutely ill with temperature of 104°F, blood pressure of 128/76 mm Hg, pulse of 98, and respiratory rate of 20. The patient has stomatitis, nuchal rigidity, and a positive Kernig sign. CSF examination shows increased opening pressure, 80 WBC/mL (normal < 10/mL), mildly elevated protein, and normal glucose. Which of the following tests would confirm the most likely causative organism? A CT of the head B polymerase chain reaction test for herpes simplex virus C blood culture for herpes simplex virus D serum IgG for herpes simplex virus E MRI of the head

polymerase chain reaction test for herpes simplex virus B The patient's presentation is consistent with viral meningitis with potential encephalitis. The presence of active stomatitis indicates herpes simplex virus as the most likely causative organism. A CT of the head could be considered prior to performing a lumbar puncture and may show temporal lobe abnormalities that support a diagnosis of herpes virus encephalitis, but like an MRI will not identify the causative organism and has limited sensitivity. Of the three herpes tests described, the PCR technique is the most likely to identify the herpes simplex virus as the causative organism in the CSF due to its high sensitivity and specificity. Serum IgG indicates prior infection from herpes simplex virus but does not confirm the causative organism of the patient's encephalitis. Viral blood cultures for herpes simplex would likely show no growth even in the presence of herpes simplex virus encephalitis

What is the most common type of hip dislocation?

posterior dislocation

ST Elevations in V1, V2

posterior wall MI, posterior descending artery

In addition to insulin and fluid replacement with 0.9% saline, which electrolyte is commonly infused in the type 2 diabetic patient who arrives in the emergency department in a hyperglycemic, hyperosmolar, nonketotic state? A bicarbonate B potassium C calcium D magnesium E sulfate

potassium Insulin not only causes cellular uptake of glucose but also of potassium. Hypokalemia may develop when insulin is infused to correct either a hyperglycemic hyperosmolar state or a diabetic ketoacidosis. Hence, in order to avoid hypokalemia, potassium chloride can be added to a saline solution, as long as the serum potassium is not elevated. (Masharani, 2008, pp. 1065-1067) Masharani U. Diabetes mellitus & hypoglycemia.

Placenta ____ typically have bright red painLESS vaginal bleeding without fetal distress. Placenta ___ present with dark, painFUL, vaginal bleeding; abdominal pain; uterine hypertonicity; and tenderness. Fetal distress often present.

previa; abruption

A 1-year-old boy is brought to the emergency department by his parents, who state that the child refuses to walk or crawl and begins crying when they stand him. Swelling to his right knee is noted; it is also warm to the touch and pain response is noted. His parents state that it seemed to start a couple of days ago and has gotten worse. They don't recall a trauma, but state that he seems to bruise easily. The child's mother states that she also bruises easily. Vitals are as follows: Temp: 38.0°C, HR: 70, RR: 15. What laboratory finding would you expect? A Prolonged aPTT (activated partial thromboplastin time) B Prolonged bleeding time C Prolonged PT (prothrombin time) D Prolonged thrombin clotting time E Thrombocytopenia

prolonged aPTT This patient has hemophilia A. Patients with severe hemophilia A have a prolonged aPTT; all of the other tests should be within the normal range.

CHF - Systolic dysfunction means a problem with the ____. What drug is contraindicated?

pump; CCB!

Treatment for ____ which presents with fever, tachycardia, and CVA tenderness is with Ampicillin & an aminoglycoside for 2 weeks.

pyelonephritis

What nerve injury is associated with an humeral shaft fracture?

radial

A 45-year-old man presents with hematemesis. He has had 2 episodes of vomiting 'coffee-ground'-appearing material; the vomiting began 45 minutes prior to presentation. Additionally, he reports passing black, sticky stools for the past 3 or 4 days. Past medical history is positive for occasional headaches; they have been coming more frequenly lately. Social history reveals alcohol use (1 case of beer each weekend) and tobacco (1 pack per day). Medications include ibuprofen as needed for headaches; he has been taking 800 mg 3 times a day for the past week. You place a nasogastric tube and find bright red blood that fails to clear with saline irrigation. Hemoglobin is 8.9 g/dL. Evaluation of his blood pressure and pulse reveals orthostatic changes that resolve with an intravenous fluid bolus of 500 cc of Lactated Ringer's solution. What should you do next? Answer Choices 1 Transfuse 2 units of packed red blood cells and recheck CBC in 8 hours 2 Check serum for Helicobacter pylori antibody 3 Order a double contrast barium swallow to evaluate for a gastric ulcer 4 Refer for emergency upper endoscopy 5 Discontinue his ibuprofen use and encourage cessation of alcohol and tobacco

refer for emergency endoscopy He should be referred for an emergency upper endoscopy. This patient is most likely bleeding from a gastric ulcer. His recent NSAID use, as well as his alcohol and tobacco habits, make him at risk for peptic ulcer disease. His symptoms of melena and hematemesis, along with his anemia, make the diagnosis quite straightforward. It appears that this patient is still actively bleeding based on the results of the nasogastric tube irrigation; therefore, the priority should be getting the ulcer to stop bleeding. Upper endoscopy should be performed so that the bleeding site can be identified and treated with electrocautery, coagulation, or injection of epinephrine or a sclerosing agent. If the bleeding cannot be stopped with endoscopic interventions, angiographic embolization should also be tried. If these interventions do not succeed, the patient has rapid deterioration, or if he requires more than 6 units of blood in a 24-hour period, then emergency surgery may be indicated. The other choices are not the best options for immediate management. This individual cannot be followed simply with transfusions and serial CBC's because he appears to still be actively bleeding. Helicobacter pylori infection may very well be playing a part in the etiology of this man's ulcer, but evaluation for H. pylori can be done with a biopsy at the time of his endoscopy; it will not help in his immediate management. A barium esophagram will not identify actively bleeding ulcers and cannot treat active bleeding. While NSAID, alcohol, and tobacco use may have precipitated this man's GI bleed, counseling about his use of these substances will not sufficiently treat his immediate bleed.

Acute _____failure is defined by an increased creatinine x3 and a decrease in GFR by >75% or urine output <0.3 mL/kg/h for 24 hours or anuria for 12 hours.

renal

What is the progression of CO2 in an asthmatic or COPD patient?

respiratory alkalosis (loss of CO2) and hypoxia THEN respiratory acidosis which indicates impending respiratory failure

_____is the separation of the sensory retina from the underlying pigmented epithelium. What is the most common location? What are the clinical manifestations?

retinal detachment; superior temporal area; "curtain came down over eye"/flashers & floaters/blurry vision

On lateral neck x-ray, prevertebral soft-tissue swelling and forward displacement of the esophagus and trachea are seen with _____. It is believed to originate from infected lymph node becoming cellulitic and ultimate abscess formation.

retropharyngeal abscess

Describe pain location, type, and other ss with... Acute Coronary Syndrome

retrosternal "crushing, tightness" pain with dyspnea/diaphoresis

Foreign body aspiration: 1. MC location of obstruction? 2. TX: ____for <1 year old; ____for >1 year old. 3. MC causes of obstruction?

right main stem bronchus; back blows for <1 year; Heimlich for >1 year; nuts, peanuts, hot dogs

A 5-year-old male is being evaluated for an acute injury to the right ankle. On the x-ray of the ankle there is a distal tibia fracture that involves the separation of the epiphysis, as well as a small non-displaced chip fracture of the metaphysis of the tibia. Based on these findings, what type of Salter-Harris fracture does this child have? A I B II C III D IV E V

salter harris 2 The growth plate is the most fragile part of the bone prior to bone maturation and thus is usually the first structure disrupted when force is applied. Statistically, Type II fractures are most common - those that involve both the growth plate and a chip fracture of the metaphysis.

A 78-year-old female trips and falls on an outstretched hand and now presents with right wrist pain. On examination, the patient complains of pain on palpation to the right radial side of the wrist near the anatomical snuffbox. Based on this clinical presentation, what is the most likely fracture that this patient has? A Capitate B Lunate C Scaphoid D Trapezium E Trapezoid

scaphoid The scaphoid or navicular bone of the wrist, is the most commonly fractured carpal bone. This injury occurs most commonly in young men. The lunate is the second most commonly fractured carpal bone and the most commonly dislocated carpal bone. The capitate is the largest of the carpal bones and it is not known as a common isolated fracture site. Fractures of the trapezium and trapezoid are relatively uncommon as well

What nerve injury is associated with an acetabulum fracture?

sciatic

Where is the needle decompression performed for a tension pneumothorax?

second intercostal space, mid-clavicular line

A 22-year-old woman, with no previous medical problems, suddenly cried out, fell to the ground, extended her legs, flexed her arms, and jerked her extremities for 30 seconds. There was associated tongue biting and urinary incontinence. She awoke slowly over a 10-minute period and recalled nothing about the episode. She remained lethargic for several hours but the rest of her neurologic examination was normal. What is the most likely etiology for this episode? A epilepsy B hyperventilation C cardiac arrhythmia D seizure E stroke

seizure D This event represents a well-demarcated episode affecting some combination of consciousness, motor, and/or sensory function consequent to abnormal electrical discharges in the brain. This is consistent with the definition of a seizure. Epilepsy refers to multiple, recurrent seizures. This history is not consistent with hyperventilation, stroke, or cardiac arrhythmia, which would typically include chest pain, shortness of breath, dyspnea on exertion, or focal neurological deficits.

A 24-year-old intoxicated male presents to the emergency department after being in a fight. He was punched in the nose, and now has mild deformity of the nose and some epistaxis. An x-ray reveals a fractured nasal bone. During his physical exam, what must you look for in order to prevent permanent destruction of his nasal septum? A Orbital fracture B Posterior epistaxis C Septal hematoma D Facial fracture

septal hematoma A septal hematoma can cause ischemic necrosis of the nasal septal cartilage if not identified and drained. A deviated septum can be expected with a nasal bone fracture, and must be addressed by the otolaryngologist. Excessive epistaxis that does not resolve with direct pressure and anterior packing may indicate a posterior bleed.

A 32 year-old male presents to the emergency department in Acute Renal Insufficiency (AKI). Which of the following conditions would be most likely observed in intrinsic AKI? A Septic shock B Congestive heart failure C Benign prostatic hypertrophy D NSAID overdose E Chronic liver failure

septic shock The most common causes of intrinsic AKI are sepsis, ischemia, and nephrotoxins, both endogenous and exogenous. Prerenal acute kidney injury can be caused from hypovolemia, decreased cardiac output, decreased circulation of blood volume (CHF, liver failure), and impaired renal autoregulation (NSAIDs, ACE-I/ARB, cyclosporine)---(E), (D), and (B). Postrenal causes include bladder outlet obstruction including bladder stones and BPH (C).

Most commonly dislocated joint in the body?

shoulder (glenohumeral)

In _____, acute painful episodes due to acute vaso-occlusion from clusters of sickled red cells may occur spontaneously or be provoked. How is the pain crisis treated?

sickle cell crisis; treat the underlying cause (ie. abx if infection suspected; hydrate well - give oxygen if hypoxic)

Which of two most common volvulus's can be treated with rectal tube insertion?

sigmoid (cecal must be treated with surgery)

Tricyclic antidepressants cause WHAT life-threatening cardiac dysrhythmias? What does treatment include?

sinus tach; prolongation of PR, QRS, and QT intervals; sodium bicarbonate as a Na channel antagonist, activated charcoal for gastric decontamination, benzos for seizures

What is the most common ECG abnormality in patients with a pulmonary embolism (PE)? A Atrial fibrillation B Sinus tachycardia C Ventricular ectopy D Sinus bradycardia

sinus tachycardia B In most cases, sinus tachycardia is the only abnormality in patients with a PE. You may also find some ECGs that will have non-specific ST-T wave changes. Sinus bradycardia and AV blocks are not common findings that are associated with PE.

Pericarditis is inflammation of the pericardium. How is pain improved? What is the PE finding?

sitting and leaning forward; ST elevation in all precordial leads, normal cardiac enzymes

What three things most commonly cause DIC ("death is coming") ie. disseminated intravascular coagulation?

snake bite, pregnancy, and sepsis

Which of the following is the initial treatment step in an adolescent who presents to the emergency department with status epilepticus? A IV glucose B stabilize airway C arterial blood gas D IV diazepam therapy

stabilize airway Status epilepticus is a medical emergency and is defined as seizure activity that lasts a minimum of 30 minutes. This results in hypoxia, acidosis, cerebral edema, and structural damage. In addition, fever, respiratory depression, hypotension, and death may occur. There are both convulsive and nonconvulsive types of status epilepticus. Because of its emergency status and potential complications, the clinician needs to initiate the ABCs (airway, breathing, circulation). Therefore, the first line of treatment is to establish and maintain an airway, oxygen is next, and then circulation, which encompasses pulse, blood pressure, and IV access. Once the IV is established, the orders should be for administering glucose-containing fluids and IV drug therapy with diazepam, lorazepam, or midazolam as well as administer phenytoin and phenobarbital. Arterial blood gases should be ordered and any abnormalities should be corrected appropriately. Finally, the clinician should determine the underlying cause: trauma, structural disorder, infection, lactic acidosis, toxins, and uremia. Maintenance drug therapy is necessary until the underlying cause is determined and rectified.

A 76-year-old male presents to the hospital with a hot, swollen, and painful right knee that appears to have an effusion. After your examination, you decide to perform an arthrocentesis. The fluid aspirate is turbid, cloudy, and most definitely looks like it is infectious material. Based on this clinical scenario, what would be most likely bacterial organism present in an elderly septic arthritis? A Hemophilus influenzae B Neisseria gonorrhoeae C Pseudomonas aeruginosa D Staphylococcus aureus

staph aureus D Septic arthritis is an infection within a joint space. The infection can be caused by multiple pathogens including bacteria, viruses, fungi and mycobacteria, but in older adults the most common organism implicated is Staphylococcus aureus. These bacteria can get into the joint space through multiple mechanisms including direct inoculation after a penetrating injury, hematogenous spread from an infection elsewhere in the body, or from extension from a contiguous bone infection. All of the bacteria mentioned as possible answers are possible causes of septic arthritis, but there prevalence varies within different patient populations. Hemophilus influenza and Streptococcus pneumonia are commonly seen in children less than five years of age that develop septic arthritis. Neisseria gonorrhoeae is most common in sexually active adolescents and young adults. Pseudomonas aeruginosa is a common cause of septic arthritis in IV drug abusers

Four factors for ____potential are given the greatest weight: 1. depression or hopelessness 2. rational thinking loss 3. organized or serious attempt 4. stated future attempt

suicide SADPERSON sex age depression or hopelessness previous attempts/psych admissions excessive alcohol or drug use rational thinking loss separated, divorced, widowed organized or serious attempt no social support

The treatment of isopropyl alcohol ingestion and ethanol ingestion is largely ____. The hallmark of isopropyl alcohol ingestion is ketosis without acidosis.

supportive

Thyroid storm is a rare life-threatening complication of thyrotoxicosis/hyperthyroidism characterized by fever, tachycardia, and dysfunction of the CNS, cardiovascular, or GI systems. What is used to treat thyroid storm?

supportive care; PTU (prophythiouracil); potassium iodine, sodium iodine, or Lugol solution; beta-blockade for peripheral effects; dexamethasone to prevent peripheral conversion of T4 to T3

Carbon monoxide should be considered when multiple individuals present from the same location with similar symptoms, known exposure to CO-producing equipment, and beginning of dormant heating units. Treatment???

supportive care; supplemental oxygen; HBO in certain populations.

Which rotator cuff muscle is most commonly injured? A Infraspinatus B Subscapularis C Supraspinatus D Teres Major E Teres Minor

supraspinatus C The supraspinatus is involved in abduction and external rotation of the shoulder joint. It is often injured in repetitive overhead activities such as swimming and throwing sports. While all muscles of the rotator cuff can be injured, the supraspinatus has been shown to sustain the most frequent injuries. The infraspinatus and teres minor are also involved in abduction and external rotation, while the subscapularis and teres major assist in internal rotation. The teres major is not considered a rotator cuff muscle

A 54-year-old man presents to the emergency department with crampy abdominal pain, nausea, and vomiting. The patient has not passed gas or had a bowel movement for at least 10 hours. On examination, the abdomen is distended and there are high-pitched bowel sounds with rushes. A plain radiograph of the abdomen reveals cecal distension to 12 cm. What is the most appropriate definitive management for this patient? A Intravenous fluids B Nasogastric suction C Observation D Surgical exploration

surgical exploration Massive distention of the cecum, as detected on plain radiograph, is typically seen in "closed loop" obstructions where the ileocecal valve is competent. When distention approaches 12 cm, there is an increased risk of perforation and/or gangrene. Expedient surgical intervention is indicated. Although observation with intravenous fluids and nasogastric decompression are important adjuncts to management, surgical exploration is the only way to rapidly address this emergent situation.

With a blowout fracture, on plain xray, a ____sign may be seen from orbital fat herniating into the maxillary sinus or the ____sign from bone fragments in the sinus.

tear drop sign; open bomb-bay door sign

A 44-year-old female presents to the emergency department with a right-sided headache. She states the headache is located on the right temple region, is non-radiating, and does not cause photophobia. She is otherwise healthy and has no reported medical problems. She only takes acetaminophen for the pain, which has minimal relief. On physical exam she is alert, awake, and oriented. Her vitals are T 98.8, P 78, R 18, and BP 128/76. Her head is normocephalic, atraumatic, and pupils are equal and reactive. She has tenderness to the right temporal area of the temporal artery, and there is no noted swelling, redness, or abnormalities noted. There is no tenderness to the cervical muscles. She exhibits a non-focal neurological exam. Based on the description, what is the most likely diagnosis of this patient? A Migraine headache B Tension headache C Cluster headache D Temporal arteritis E Takayasu arteritis

temporal arteritis D This patient is exhibiting a case of temporal arteritis (D). She has the signs and symptoms that are classic in nature and do not fit into the realm of the other headaches (A, B, and C), all of which usually have different characteristics on history and physical exam. Takayasu arteritis (E) will typically not present in the temporal artery.

A 14-year-old boy presents to the emergency department with acute scrotal pain and vomiting for the past 2 hours. His left testicle is in extreme pain and he states the pain started while playing basketball in gym class. Which diagnosis is highest on your differential in regards to his clinical presentation? A Epididymitis B Hydrocele C Testicular torsion D Varicocele E Intrascrotal tumor

testicular torsion C Testicular torsion (C) is most common between ages 12-18 with the classic presentation of abrupt and severe onset of pain with nausea/vomiting. The most common cause of painless scrotal swelling in children is a hydrocele (B). Epididymitis (A) usually has an insidious onset, commonly presenting with urinary frequency, dysuria, or fever. Varicoceles (D) and intrascrotal tumors (E) usually present as painless scrotal edema.

The most common intracranial aneurysm is a saccular or berry aneurysm and located where? Treated with surgical clipping

the circle of Willis or its major branches

A patient presents to the emergency department with signs and symptoms of acute pancreatitis. He does not drink alcohol and has no history of gallstones. He has a positive history of increased lipids. Very high levels of which of the following lipids is associated with an increased risk of pancreatitis? A High density lipoprotein B Low density lipoprotein C Apolipoprotein C D Total cholesterol E Total triglycerides

total triglycerides The correct choice is E, total triglycerides. Very high levels of triglycerides increase the risk of acute pancreatitis, probably from local release of free fatty acids and lysolecithin from lipoprotein substrates in the pancreatic bloodstream. If the albumin binding capacity is exhausted, these fatty acids can initiate a chemical pancreatitis and destroy parenchymal cells in the area.

A 33-year-old IV drug user presents to the emergency department with pleuritic chest pain, cough, chills, diaphoresis, anorexia, and malaise. On physical exam, her temperature is 40°C, BP 98/55, P 115 bpm, and RR 22. No murmur could be appreciated. Two separate blood cultures are positive for S.aureus. An EKG, CXR, and transesophageal echocardiogram are ordered. Which of the following lesions is most likely to be seen on TEE in this patient? A Aortic valve vegetation B Tricuspid valve vegetation C Mitral valve vegetation D Left ventricular hypertrophy E Ventricular septal defect

tricuspid valve vegetation In almost 50% of cases involving IV drug users, the only site of infection is the tricuspid valve, and most lesions are right-sided, so choice B is the most appropriate answer. Left ventricular hypertrophy, choice D, is seen in patients with a history of hypertension. Choice E, ventricular septal defect, is frequently associated with a holosystolic murmur.

What are some drugs associated with Torsades de pointes?

tricyclic antidepressants, erythromycin, ketoconazole, haloperidol, cisapride, disopyramide, pentamidine, sotalol, class I anti-arrhythmics

A fracture involving the medial epicondyle will most likely cause damage to which nerve? A Axillary B Median C Peroneal D Radial E Ulnar

ulnar Because the ulnar nerve passes through the cubital tunnel, which is a groove on the posterior aspect of the medial epicondyle, any fractures involving the medial epicondyle can also cause damage to the ulnar nerve. The median nerve is most susceptible to injury at the carpal tunnel. Branches of the radial nerve can become entrapped on the lateral side of the elbow and the associated symptoms are often confused with lateral epicondylitis. Radial nerve injuries are more commonly associated with humeral shaft fractures. The axillary nerve is significantly proximal to the medial epicondyle and the peroneal nerve is in the leg

Spinal cord injuries - the following injuries are _____: Teardrop fracture, bilateral facet dislocation, atlantooccipital dislocation, atlantoaxial dislocation, hangman's fracture, burst fraction, and Jefferson fracture.

unstable or potentially unstable

A 59-year-old woman presents to the emergency department with an acute upper gastrointestinal hemorrhage. Her medical history is pertinent for peptic ulcer disease for the past 5 years and hypertension. A nasogastric tube is inserted and bright red blood is seen. Her vital signs are BP: 110/70 mm Hg, P: 94/min, R: 14/min, oxygen saturation: 97%, T: 99°F. Which of the following diagnostic studies would be the most appropriate next step to determine the site of bleeding? A Abdominal and pelvic computed tomography B Abdominal ultrasound C Upper gastrointestinal series with barium D Bleeding scan E Upper endoscopy

upper endoscopy Patients who present with upper gastrointestinal bleeding and shock requiring multiple transfusions in 24 hours are at high risk for mortality from gastrointestinal bleeding. The upper gastrointestinal bleeding in this patient warrants further investigation with upper gastrointestinal endoscopy to both determine the site of bleeding and provide potential therapy by endoscopic electrocautery or injection.

Pertussis: Catarrhal stage - 1-2 weeks - resembles a ____ Paroxysmal stage - 2-4 weeks - _____ Convalescent stage - 1-2 weeks - ______. Nasal swab culture for Bordetella pertussis is diagnostic.

upper respiratory infection; whooping cough; cough disappears

Patients with unruptured ovarian cysts less than 5cm can be treated how?

usually can be treated w NSAIDs and will involute in 2-3 menstrual cycles

Paroxysmal supraventricular tachycardia is a reentry tachycardia, commonly noted in elderly patients with underlying heart disease. What treatment may be helpful before using adenosine ie. the drug of choice?

vagal maneuvers or antianxiety medication

Mallory-Weiss tears occur after a bout of retching -- from bleeding that involves tears of the underlying _____.

venous or arterial plexus

Virchow's Triad for DVT?

venous stasis, endothelial injury, hypercoagulable state

Laryngitis is most commonly due to ____agents although bacterial causes are Strep pyrogenes or M cat. Treatment is supportive with voice rest, warm saline gargles, and increased humidity.

viral

What is the most common pathogen that causes an acute bronchitis? A Viral B Bacterial C Fungal D Unknown

viral A Respiratory viruses are the most common cause of acute bronchitis. In clinical medicine, it is rare to obtain cultures for patients who present with bronchitis symptoms.

Pharyngitis Etiology: Rhinorrhea suggests ___etiology. Pharyngeal exudates suggests ___etiology. Vesicles or ulcers suggests ___etiology. Conjunctival congestion suggests ____.

viral; bacteria (Strep or Epstein Barr); herpes simplex; adenovirus

Prolonged bleeding after a traumatic episode. Normal PT and PTT. Dx and tx.

von Willebrand disease -Desmopressin = mainstay of tx -Factor 7 concentrate (if type 2 or 3 vWF)

A 70-year-old woman who was found barely responsive at home by her daughter is brought to the emergency department. Evaluation reveals that she is in a hyperglycemic hyperosmolar state with a severe fluid deficit. Treatment is initiated with vigorous saline rehydration and a continuous infusion of insulin. At what point should her glucose be added to her treatment? A when her condition becomes stable B when her urine output reaches 50 mL/hour C when her blood glucose reaches 250 mg/dL D if she develops hypokalemia E if she begins to spill ketones in her urine

when her blood glucose reaches 250 mg/dL In hyperglycemic hyperosmolar states, the serum glucose rapidly corrects with fluid administration alone. However, with vigorous rehydration, glucose may fall precipitously and lead to severe hypoglycemia. To avoid this, glucose should be added to water, half-normal, or normal saline as soon as the patient's blood glucose is less than or equal to 250mg/dL. She should continue to receive insulin IV until she is stabilized (A) when it can be switched to subcutaneous administration. The goal of fluid therapy in this patient is restoring her urine output to 50 mL per hour (B) or more. Because insulin drives potassium into the cells and can cause hypokalemia (D), potassium chloride should be given unless the patient has chronic kidney disease or oliguria. Persons in a hyperglycemic hyperosmolar state typically do not spill ketones (E) the way persons with diabetic ketoacidosis do.

A 66-year-old male with a history of hypertension, diabetes mellitus, and hypercholesterolemia presents by emergency medical services (EMS) to the emergency department complaining of severe chest pain with radiation into his back. The patient states that he was feeling well in the morning, but while performing some light activity he felt a "ripping" sensation in his back, which he initially thought was a pulled muscle. The pain continued and the patient started to have chest pain, shortness of breath, and lightheadedness. On initial examination the patient is still in pain, pale, diaphoretic, and has a blood pressure of 85/40. His chest is clear to auscultation, and he has a 3/6 diastolic murmur best appreciated at the base of the heart. Given this clinical scenario, what would be the expected finding on chest x-ray? A Normal B Pleural effusion C Decreased lung volume D Widened mediastinum E Cardiomegaly

widened mediastinum

Gastric Decontamination of Toxins: Timeframe for emesis/lavage?

≤1hr of ingestion