Emergency Medicine EOR

History to collect in Trauma setting?

"AMPLE" - Allergies - Medications - Past medical history - Last meal and last tetanus - Events preceding the injury

What are clinical features of Impetigo?

"Honey colored crust" Erythematous macules, vesicles, bullae Often occurs in pre-existing skin conditions such as eczema

What are clinical features of a aortic dissection?

"Ripping or "tearing" chest pain radiating to the back Severe back, abdominal, flank pain Hypotension/shock

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

How do you determine severity of burns?

% of skin burned Depth

presentation of a peritonsilar abscess

(kid) w/ sore throat (worst sore throat that they've ever had), hot potato voice, difficulty breathing; physical exam reveals deviated uvula, large tonsil

Shock Work up

*History, history, History* CBC, CMP, UA, Trop, Coag Panel, hCG, ABG, Lactate CXR EKG Cultures

CVA Workup and DDX

*Hypoglycemia*-CHO CBC, INR/aPTT, BMP EKG,Trop Stat Head CT Carotid US ECHO

Epidural Hematoma

*Lucid Interval* MMA Biconvex May be relieved by burr hole

presentation of bronchial carcinoid tumor and carcinoid syndrome

*persistent coughing* with *hemoptysis* and focal wheezing. As these tumors begin to secrete hormonal mediators, they may cause carcinoid syndrome during which symptoms can include *diarrhea, flushing, head and neck edema, bronchospasm, or hives.* suspect in patients with recurrent pneumonia most dx in central bronchi CT surgical excision

What are clinical findings of a spontaneous abortion?

+/- Vaginal bleeding Uterine size does not correlate with LMP Fundus of uterus may be boggy or tender Abdominal cramping

What is a threatened abortion?

+Vaginal bleeding Cervix is closed Products of conception have not passed

What is a complete abortion?

+Vaginal bleeding Cervix is open All products of conception have passed

What is an inevitable abortion?

+Vaginal bleeding Cervix is open Products of conception have not passed, but no way to save pregnancy

What is an incomplete abortion?

+Vaginal bleeding Cervix is open There is partial passage of products of conception

Extraperitoneal perforation of bladder

- "Flame shaped" contrast density lateral to bladder

Causes of Pulseless Electrical activity (PEA)

- 6 H's and 6 T's - Hyperkalaemia -------Tamponade - Hypoxia - ---------Tension Pneumo - Hypothermia --------- Thrombosis - Hydrogen Ion ------ Toxins - Hypovolemia ------ Trauma - Hypoglycemia

Positive test for Diagnostic peritoneal lavage

- >100,000 RBC/mm3 - > 500 WBC's/mm3 - Bacteria on gram stain

Tx of Spinal Cord injury

- ABCs - High dose methylprednisolone in blunt trauma pts

Tx of Spinal cord injury

- AIRWAY - High-dose methyprednisolone for blunt trauma pts

Indications of Posterior urethral injury

- Abdominal pain, perineal pain and inability to void - Blood at meatus

Nexus Criteria

- Absence of tenderness in posterior midline - No evidence of intoxication - Normal mental status - Absence of a neurological deficit - No painful distracting injuries

Options for STABLE Blunt Trauma pt

- Admit with serial exams; vitals every 15-30 min - FAST Scan and U/A - CT scan abdomen/pelvis - Labs

Types of Distributive shock

- Anaphylactic shock - Septic shock - Spinal Shock

Dx of Aortic Disruption

- CXR ( Screening tool) - CT scan ( Highly sensitive, readily available)

Dx of Pulmonary contusion and hematoma?

- CXR (May be negative initially) - CT scan (More sensitive)

Conditions in which Pulsus Paradoxus is found

- Cardiac Tamponade - Pericarditis - Cardiogenic shock - Asthma/COPD - PE - Tension PTX - Hypovolemia - Pregnancy

Types of Obstructive shock

- Cardiac tamponade - Massive PE - Tension PTX

S&S of Cardiac Tamponade

- Chest pain - Dsypnea - Beck's Triad (Decreased BP, Muffled heart sounds, JVD) - Kussmaul sign

Subdural Hematoma

- Collection of blood between the dura mater and the arachnoid layer - Sudden acceleration-deceleration causes shearing of bridging veins - Alcoholics and elderly are more susceptible

Septal Hematoma

- Collection of blood between the mucoperichondrium and the cartilage of the septum - Appears as a blue, boggy, tender area of swelling along the nasal septum

Overall Tx for abdominal trauma

- Crystalloids (IVF) - pRBC - Factor VIIa if there is major bleeding -Tranexamic acid

Mac blade

- Curved blade goes into vallecula and allows visualization of trachea by moving epiglottis

Risk factors for necrotizing skin infections

- ETOH - DM - Prolonged bed rest

ECG findings in Cardiac Tamponade

- Electrical Alternans (Alternating high/low voltage QRS due to changing distance of heart from electrodes)

Signs of Pancreas injury

- Epigastric or back pain - Fluid around pancreas - serum enzyme levels - Grey-turner or Cullen sign

Ellis II fracture

- Exposed area should be covered with calcium hydroxide paste, glass ionomer, or a strip of adhesive barrier - Involves dentin as well as the enamel - Require dental involvement within 24 hours

Components of Glasgow coma scale

- Eye response - Motor Response - Verbal Response - Lowest total is 3, highest is 15

Dx of Cardiac Tamponade

- FAST exam is first choice - Transthoracic or Transesophageal echo (when you have more time to dx pt)

Options for UNSTABLE Blunt Trauma pt

- Follow ATLS - FAST Scan - Operating Room if pt is unstable - labs

Le Fort II Fx

- Fracture extends through the maxilla, maxillary sinuses, nasal bones and infraorbital ridge - Facial tugging moves the upper palate and the nose but NOT THE EYES

Signs of Duodenal injury

- Frontal impact - Bloody NGT output - Retroperitoneal air - Feeling full, pressure, pain, inability to eat

Indications for CT imaging of brain in head trauma

- GCS <15 - Loss of consciousness - AMS - Vomiting - Seizure - Amnesia - age >65 years

3 causes of Hypovolemic shock

- Hemorrhage - Dehydration - Third Spacing

Areas Scanned in a FAST scan

- Hepatorenal recess (Morrison's pouch) - Perisplenic space - Pericardium - Pelvis

Cervical Spine Sprain (Whiplash)

- Hx of abrupt hyperextension - Pts have neck pain/ spasm and headache - NO evidence of neurologic deficit and NO fx on C-spine films - Tx- Immobilization with cervical collar from hours to days

How is the dysautonomia of neurogenic shock manifested?

- Hypotension - Bradycardia - Peripheral vasodilation

Decorticate posturing

- Indicated intracranial injury above level of midbrain

When would a CT be indicated in pts with a mild TBI?

- Intoxicated pts - Pts who cannot be reliably observed after release - Pts on anticoagulants - Pts > 65 y/o

Class II Hemorrhagic shock

- Lose up to 1500 mls of blood - Tachycardia and Tachypnea - Decreased Pulse pressure

Class 1 hemorrhagic shock

- Loss of 15% of blood volume - Minimal tachycardia - No measureable change in BP, Pulse pressure, and RR - Body can compensate well

Class III Hemorrhagic Shock

- Loss of 30-40% of blood volume (2000 cc's) - Measurable drop in BP - Narrowing Pulse pressure - Marked Tachycardia and Tachypnea - Mental status change - Decrease in urine output

Tx of Flail chest

- Maintain ventilatory support - Supplemental O2 - Pain control

Le Fort I fx

- Maxillary fracture that extends to the nasal aperature - airway complications are uncommon - Maxillofacial surgery should be consulted with the ED

Tx of Pulmonary contusion/ hematoma

- Mechanical ventilation - High frequency oscillation - IVF

Class IV Hemorrhagic Shock

- More than 40% blood lost; loss of > 2000 ml's - Unconscious - Skin is cold, and clammy, diaphoretic - No urine output - Heading to irreversible shock

Management of Class I and II hemorrhagic shock

- NL saline, lactated ringers (Volume expander)

What drugs should be avoided when a pt is in cardiogenic shock?

- Nitrates - Beta blockers - Calcium channel blockers

Epidural Hematoma

- Occur from blunt trauma to the temporal or temporoparietal area - Rupture of middle meningeal artery - Loss of consciousness followed by a lucid interval - Looks like a football on imaging

Management of tongue laceration

- Pack with gauze and pressure to visualize source - Lidocaine with 1% epi or cauterization may be necessary

Management of Class III and IV hemorrhagic shock

- Packed RBC

Tx of Rib Fx

- Pain Control - Incentive Spirometry - Positioning, Oscillation - NO immobilizers/binders

Sxs of flail chest

- Pain and Respiratory distress - Paraodoxical chest wall movement - Crepitus - Respiratory Failure

Evidence of urethral injury

- Pelvic crush injury - Blood at meatus - Distended bladder - No urine output from catheter

How to assess quality of Chest Xray

- Penetration - Inspiration - 8-10 ribs - Rotation - Angulation

If you clinically Dx a Tension Pneumothorax, what should your next step be?

- Proceed directly to management and Tx

Signs and Symptoms of Pneumothorax

- Respiratory distress/ tachypnea - Hypoxia -Hypotension - Distended neck veins - Absent breath sounds on affected side

Ellis IV fractures

- Root fractures that involve the alveolar bone - Require stabilization of adjacent teeth with dental resin or ligature wire

Risk Factors for a pneumothorax

- Smoking - Pulmonary disease - Age (20-40) - Tall, thin, male - Family hx - trauma

Miller blade

- Straight blade goes right over epiglottis and pushes it out of the way manually

Commotio Cordis

- Sudden cardiac death or near sudden cardiac death after blunt, low impact chest wall trauma - Impact occurs 10-30 ms prior to peak of T wave

Signs of Bowel injury

- Sudden deceleration injury - Free fluid in absence of solid organ injury - Free air

Management of Small PTX

- Supportive care - Supplemental O2 - Monitor - Discharge if no progression after 6-8 hours

Zone 1

- Suprasternal notch and clavicle border to the inferior cricoid

Central Transtentorial herniation

- Symptoms may progress from pinpoint pupils and increased muscle tone to hyperventilation and decorticate posturing

Spinal Shock

- Temporary loss of spinal reflex activity that occurs below a complete or incomplete spinal cord lesion - Loss of all neurologic function below the level of the lesion

Tx of Cardiac Tamponade

- Thoracotomy is TOC - Pericardiocentesis can be done to provide immediate decompression

Spinal Cord injury without obvious radiologic abnormality (SCIWORA)

- Transient or persistent neurologic symptoms in a pt without evidence of fracture or dislocation on plain films and/or CT

Tx of Tension pneumothorax

- Tube thoracostomy - Requires definitive Chest tube placement

Labs to order in Abdominal trauma

- Type and screen - CBC -I-stat - Chemistry - ABG - Lactate - AMylase -HCG (ALWAYS FOR FEMALES) - ETOH

3 impacts in an MVA

- Vehicle Impact - Body Impact - Organ Impact

Rapid Sequence Intubation

- is a medical procedure involving a prompt induction of general anesthesia and subsequent intubation of the trachea. RSI is typically used in an emergency setting or for patients in the operating room.

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

Lethial Triad in trauma

-Acidosis - Hypothermia - Coagulopathy

Primary Survey

-Airway -Breathing -Circulation -Disability -Exposure

Constraint of disposition

-As an EM practitioner you must do something for each pt that presents to you whether they receive diagnostic studies or lab work

Cerebral contusion

-Blood vessels break and leak causing pooling of blood in brain tissues - non-space occupying lesion within the brain itself - Less likely to cause brainstem hernation

Le Fort III Fx

-Craniofacial dysjunction - Entire face shifts when you tug on teeth - Airway COMPROMISE IS COMMON - Nasogastric and nasotracheal tubes are contraindicated

Tx of Anterior nose bleed

-Direct presure -Vasoconstrictors -Cauterization - Packing

Cardiogenic shock

-Failure of the heart to pump blood to the rest of the body

Signs and symptoms of Upper urinary tract trauma

-Flank or abdominal pain - N/V - Lower rib fx - Any penetrating wounds whose trajectory crosses the paravertebral gutter

Tx of Extraperitoneal rupture of the bladder

-Foley drainage for 7-15 days with 20Fr or greater sized catheter

Central cord syndrome presents with?

-Greater motor weakness in the upper extremities than in the lower extremities

Tx of Septal Hematoma

-Incision and drainage is requires to prevent necrosis of the septal cartilage and resultant saddle deformity

What causes Acute Labyrinthitis & Vestibular Neuritis?

-Infection or inflammation of the inner ear, usually due to latent virus -Neuritis = only semicircular canals affected -Labyrinthitis = vertigo + hearing loss

Brown-Sequard presentation

-Ipsilateral loss of proprioception and motor function - Contralateral loss of pain and temperature sensation

Chronic subdural hematoma

-May or may not present with history of head injury - See in elderly and alcoholics - HYPODENSE lesion on CT scan

Appropriate solutions to transport a tooth?

-Milk - Saliva - Saline - Hank's or Viaspan solution

Signs of Hypoperfusion

-Obtunded - Cool skin temp - Delayed capillary refull - Decreased Pulses

What are the s/s of retinal detachment?

-Sudden painless loss of vision "like a curtain covering the eye" -May see flashes or floaters or cuts or lines in vision

Hallmarks of Shock

-Tachypnea - Tachycardia - Narrowing pulse pressure

In a massive hemothorax what will you see on CXR?

-White out on CXR - Blunting of costophrenic angle

Tripod fracture

-fracture of the zygomatic arch -fractures of the inferior orbital rim and anterior and posterior maxillary sinus walls -fracture of the lateral orbital rim

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

0.5 to 1.0 mL/kg/hour of urine output

What are the EKG findings of a STEMI?

1 MM ST segment elevation in two contiguous leads

How do you treat VVC?

1 day, 3 day, or 7-14 day treatment duration. 1 day: Butoconazole cream Fluconazole 150mg PO - preferred Ticonazole cream

Surgical management of hemothorax is indicated when?

1-1.5 L of blood loss OR > 200 ml/hr x 2-4 hrs

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

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

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

What are three major risk factors for CHF?

1. Hypertension - causes chambers of heart enlarge and weaken 2. CAD - ischemia damages cardiac muscle 3. Valvular heart disease - dysfunctional valves cause the heart to have to work harder which causes failure over time

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

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

when a patient presents with an S3 gallop, particularly when accompanied by pulsus alterans (arterial pulse waveform showing alternating strong and weak beats) - what are the following? (reduced or elevated) 1. LV pressure 2. ejection fraction 3. BNP

1. elevated LV filling pressure 2. reduced EF 3. elevated BNP

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

tetralogy of fallot 4 abnormalities?

1. pulmonary stenosis 2. right ventricular hypertrophy 3. overriding aorta 4. ventricular septal defect

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)

3 Components of Glasgow coma scale?

1.)Eye opening 2.) Verbal Response 3.) Motor Response

What are three common causes of EM?

1.Drugs (sulfonamides, phenytoin, barbiturates, PCN, allopurinol) 2. Infections (HSV, Mycoplasma) 3. Idiopathic: 50% of cases

Epistaxis Posterior

10%, Elderly, coagulopathy *Sphenopalatine artery* Posterior packing, ENT consult, admit, antibiotics

Normal Intracranial pressure

10-15 mmHg for adults

How do you manage acute burns?

100% O2 with pulse Ox Early intubation with any signs of inhalation injury Determine tetanus status Fluid resusictation for all burns >20% Foley NG/OG tube Prevent hypothermia Silvadene

HR range for simple tachyarrhythmia

100-150bpm

HR range of atrial tachycardia

125-250bpm

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

target BP goal (for MI patients?) w/ comorbidities of DM, HF, renal insufficiency)

130/80mmHg

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

140/90; 160/100

HR range for paroxysmal tachycardia

150-250bpm

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

generally speaking, phosphate supplementation is not recommended in DKA or HHS patients; the exception is if the phosphate drops below a certain value... what is that value?

1mg/dl aka 0.32mmol/L

When is a CT scan indicated for Rib fx?

1st and last 3 rib involement

What are the AV blocks?

1st degree: prolonged PR 2nd degree (Wenchkebach): longer, longer longer PR then dropped beat 2nd degree, type II: intermittent nonconducted atrial beats 3rd degree: complete dissociation of atria and ventricles. They both beat randomly and are unsynchronized

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

Diagnostic studies for amenorrhea?

1st line: Beta hCG, TSH, Prolactin Other: FSH, LH, Estrogen, Testosterone Genetic testing

Generally pts with a mild TBI can be Discharged after _____ hours of observation

2 hours

What percent of patients with unstable angina will have a normal EKG?

25%

What is considered a major burn in adults? Peds?

25% adults 15% peds

HR range for atrial flutter

250-350bpm

Clinical features of pericarditis? What are the three classic features of pericarditis?

3 classic features: Pleuritic, sharp chest pain (relieved by sitting upright/leaning forward), Diffuse ST elevation, Friction rub Constrictive pericarditis causes dyspnea, fatigue, weakness, edema, hepatomegaly, ascites

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

Diagnostic labs for endocarditis?

3 sets of blood cultures at least 1 hour apart before starting antibiotics

What is considered an adequate trial of a COC for endometriosis?

3-6 months taken continuously

What is minimal urine output for burn patients?

30 ccs

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

30-60

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

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 can it take to pass a kidney stone?

4-6 weeks, so you may see a patient in the ED but can discharge them

Packing for anterior nose bleed should be left in for how long?

48 hours and prophylactic ABX should be started

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.

Endotracheal tube should be placed about ____ cm from the carina

5 cm

What is the yearly risk of an emoblic event with A.fib?

5%. Lifetime risk is 25%

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 classic signs/symptoms of acute arterial occlusion?

6 P's: Pain Paralysis Pallor Paresthesia Poikilothermia (cold) Pulselessness

Outer skin on a lip laceration should be closed with?

6-0 Nylon

What is the prevalence of endometriosis?

6-10% of women in the US

A minimum CPP of ____ mmHg is requires to perfuse the brain

60 mmHg

how to calculate the target HR for a stress test

80% maximum for age

What percent of spontaneous abortions occur in the 1st trimester? What percent of this is associated with a chromosomal abnormality?

80%; 80%

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

When can fetal heart tones be appreciated?

9-12 weeks

Mean arterial pressure (MAP) should be maintained above?

90 mm Hg

Epistaxis Anterior

90%, Trauma, dry air, URI, infection *Kiesselbach's Plexus* Look for source, Cautery, Gelfoam/Surgicel, Packing, ENT follow up

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

Cholecystitis

95% Caused by Cholelithiasis 5Fs- * Fat, Forty, Female, Fertile, and Fair* Sudden RUQ pain, radiates to back, associated with fatty meals, N/V, *Arrest of inspiration on palpation RUQ-Murphy's sign*

How do you interpret BNP levels?

<100 is unlikely to be CHF 100-500 is may be CHF 500 is likely to be CHF

Grade IV liver laceration

>10 cm deep

What burns qualify for the Parkland formula?

>20% BSA burned (2nd and 3rd degree burns only)

HR of afib

>350bpm

What drug is indicated next for a patient who remains in VF cardiac arrest after defibrillation & epinephrine 1 mg IV? a. amiodarone 300 mg IV b. Lidocaine 1 to 1.5 mg/kg IV push c. Procainamide 50 mg/min, up to a total dose of 17 mg/kg d. Magnesium 1 to 2 g, appropriately diluted, IV push

A

Which of the below patients should receive Adenosine for initial treatment of their condition? a. 44 y/o alert female with PSVT with rate of 170/minute b. 65 y/o male complaining of chest pain, with ECG showing atrial tachycardia with rate of 140/minute c. 60 year old female with dizziness, chest pain, BP of 88/60 with ECG showing atrial fibrillation with ventricular response of 115/minute d. 70 y/o male with palpitations, agitation and ECG wthat shows wide complex tachycardia with rate of 200/minute

A

Which of the following is indicated in the treatment of a patient with hypotension and a Mobitz type 2 heart block? a. Atropine b. Synchronized cardioversion c. Transcutaneous pacing d. Epinephrine 1 mg IV

A

What is Stanford A and B?

A - Involves ascending aorta B - involves descending aorta

What is Mastitis? Who does it most commonly occur in? What bug causes it?

A breast infection that occur primarily in lactating women. Caused by S. Aureus

What is the most common arrhythmia?

A fib

Basilar skull fracture

A fracture involving the temporal, occipital, ethmoid and/ or sphenoid bones - Associated with tearing of the dura and CSF leaks - raccoon eyes, Battle sign

Tx for type A aortic dissection? B?

A is treated with excision of tear and a portion of the ascending aorta, replacement with aortic graft, and repair or replacement of the aortic valve B is treated medically with tight BP control with BB and afterload reducers (Nitroprusside). May need surgery.

What is an acute MI?

A result of prolonged myocardial ischemia, usually as a result of a thrombus formation on a disrupted or eroded atherosclerotic plaque. 1/5th of patients will die from V.fib

What is Stevens-Johnson Syndrome (SJS)?

A vesiculobullous disease of the skin, mouth, eyes, and genitalia. Ulcerative stomatitis leads to hemorrhagic crusting. <10% skin loss

What is the MOA of Danazol?

A weak androgen - it inhibits gonoadotropin release at the hypothalamus so there is no FSH/LH surge mid-cycle. This prevents growth of endometrial tissue.

Initial assessment and resuscitation of the burn patient?

ABCDEs Check urine output Check for eschar and compartment syndromes

first thing that needs to be assessed in any patient, especially true of mental impairment (i.e. stroke)

ABCs

How do you manage a hemodynamically unstable patient with vaginal bleeding?

ABCs 2 large bore IVs Labs: CBC, CMP, T&C, Pregnancy test, PT/PTT, UA Cardiac monitor/pulse ox Crystalloid Fluids Blood Control hemorrhaging GYN consult

everyone w/ HF needs to be on at least two meds... waht are these meds (classes)

ACEI, BB; also often add a diuretic (diuretics are sulfa drugs) such as fureosemide, may subsequently add spironolactone

Altered Mental Status

AEIOU: Alcohol, Endocrine/Electrolytes, Infection, Oxygen/Opiates, Uremia TIPS: Trauma/Temperature/Toxins, Insulin, Psychiatric/Porphyria, Stroke/Schock/SAH

What is German Measles?

AKA "RUBELLA" Symptoms last 2-3 days Half of patients with Rubella are asymptomatic

What is Scarlet fever?

AKA "SCARLETINA". Most commonly affects children between 5 and 12 years of age. Caused by GAS which release erythrogenic exotoxin.

What are endometriomas?

AKA "chocolate cysts". Caused by endometriosis. They are pelvic masses with thick fibrotic walls and filled with old blood.

What is Erythema Infectiousum?

AKA 5th disease Caused by Human Parvovirus B19

What is stable angina?

AKA Angina pectoris Episodic angina that persists for years in some patients Lasts 5-20 minutes Relieved by nitro, O2, rest ST depression/T wave inversion

What is Roseola?

AKA Exanthem Subitum Caused by human herpesvirus 6 (HHV-6) Occurs in infants ages 6 months - 3 yo

What are clinical features of Measles?

AKA Rubeola 3 C's: Cough, Coryza (cold-like symptoms), Conjunctivitis 4 day fevers KOPLIK's SPOTS- oral lesions that appear before the rash Macular-papular rash in the hairline that spreads down over 3 days

What is prinzmetal angina?

AKA Variant angina. Spasm of the epicardial vessels in patients with normal coronary arteries. Typically occurs at rest and is brought on by use of tobacco or cocaine. EKG shows ST elevations during an attack.

What are the drugs of choice for V.Tach in a stable patient? What is the preferred order?

ALP= Amiodarone, Lidocaine, Procainamide

cardiac involvement needs to be put into the ddx for abdominal pain. why?

AMI can present w/ abdominal pain.

Chest pain DDx

AMI, Angina, Aortic Dissection, PE, Community Acquired Pneumonia, Pneumothorax,Pleurisy, Pericarditis, GERD, Esophageal Spasm, Malignancy, Musculoskeletal, EDA, Shingles

What are the s/s of myxedema coma?

AMS -Hypothermia -Hypotension, bradycardia, hyponatremia, hypoglycemia, hypoventilation -Edema of hands and face -Thickened nares, swollen lips, or enlarged tongue

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

How do you distinguish AS from hypertrophic obstructive cardiomyopathy?

AS decreases with Valsalva Hypertrophic cardiomyopathy increases with Valsalva (decreases with squatting and hand grip)

How do you distinguish AS from MR?

AS radiates to the carotids

Where do AA occur? Which is more common?

Abdominal (90%) Thoracic (10%)

Diagnostic studies for AAA?

Abdominal US is study of choice!

What should be on your Ddx for musculoskeletal pelvic pain?

Abdominal wall myofascial pain - will have trigger points Chronic back pain Fibromyalgia Lower back pain

What is Dysfunctional uterine bleeding (DUB)?

Abnormal uterine bleeding in the absence of an anatomic lesion. Usually caused by a problem with the hypothalamic-pituitary-ovarian hormonal axis. Most commonly occurs after menarche and in perimenopause.

What is the MC cause of 3rd trimester bleeding?

Abruptio placentae

What are complications of abruptio placentae?

Abruption can lead to activating the extrinsic clotting mechanism which can cause DIC Compromised to placental blood flow Hemorrhage Renal failure Coagulation failure Death

What patterns on fetal monitoring indicated fetal distress?

Absence of baseline variability Bradycardia (FHR<110) Recurrent variable or late decelerations

How is Hyperosmolar Hyperglycemic State different from DKA?

Absence of ketones, BS is usually over 1000

What is secondary amenorrhea?

Absence of menses for 3 months in a woman who has previously menstruated. If a woman has an irregular period, then it must be 6 months

What is primary amenorrhea?

Absence of menstruation by age 16

Complete spinal cord lesion

Absence of motor or sensory function below the level of the lesion

What are the different patterns of fetal heart rate?

Accelerations - increase of 15bpm for 15 seconds above normal rate. Indicates fetal well being Early decelerations - decrease in heart rate before contractions begin. Considered benign. Variable decelerations - rapid drops in fetal heart rate with a return to baseline with variable pattern. If mild and infrequent considered benign. If not, could be caused by cord compression. Late decelerations - fetal heart rate drops during 2nd half of contractions. Denotes fetal distress

Pustular Drug Eruption

Acne like eruption with no comedones-can occur on arms/legs Generalized eruption - febrile, leukocytosis Caused by drugs

What are SE of Danazol?

Acne worsening Voice deepening Weight gain Edema Adverse lipid profile

What are conditions other than an MI that troponins can be elevated in?

Acute and chronic HF Cardiomyopathy Pericarditis, myocarditis LVH Severe HTN Arrhythmias (A.fib, SVT) Sepsis Stroke Strenuous exercise

______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

Ddx of acute MI?

Acute aortic dissection PE Tension pneumothorax Esophageal rupture GI cause: esophagitis Pulm: Pleuritis, PNA Chest wall pain Psych: Anxiety, depression

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

Acute leukemia

What should be on your DDx with vaginal bleeding and a negative pregnancy test?

Acute menorrhagia Truama GYN infections Ruptured ovarian cyst Ovarian torsion FB Coagulopathy Cancer DUB UTI

What is acute arterial occlusion?

Acute occlusion of an artery usually by embolization or thrombosis

What are chronic complications that occur from PID?

Adhesions which can lead to: Ectopic pregnancy Infertility Chronic pelvic pain

When do you administer an antiarrhythmic drug with V.fib?

Administer Amiodarone after 2 cylces of CPR and defibrillation (Lidocaine is 2nd line)

WHat is the tx for myxedema coma?

Administer loading dose T4 followed by daily dose -Also give T3 (more rapid onset) until pt is stabilized with clinical improvement *Passive rewarming

What is the tx for orbital cellulitis?

Admit for IV antibiotics (amoxicillin or ceftriaxone + vanco for severe cases)

Torsed Gonad Female

Adnexal tenderness to palpation and possibly mass Must exclude ectopic pregnancy Pain control Prompt OB/GYN consult Ultrasound Laparotomy

What are characteristics of irritant contact dermatitis?

Affected area is sharply marginated and confined to area of contact. Signs: Erythema, vesicle, erosion, crust, scale Could occur within a few hours or over months

What patient factors do you need to consider when treating endometriosis?

Age Extent of disease Symptoms Fertility

What should always be checked first in a trauma victim?

Airway

What must be managed first in any trauma pt?

Airway!

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)

What are management strategies for the first stage of labor?

Ambulation if tolerated If patient wants to be supine, best in lateral position to prevent compression of SVC IV fluids Labs - CBC, T&S Consider rupture of membranes Provide analgesia

What are common symptoms of pregnancy? (7)

Amenorrhea N/V Breast tenderness Quickening Easy fatigability Change in appetite Urinary frequency, nocturia, infection

What is Erythema Multiforme (EM)?

An acute inflammatory disease which is usually induced by drug hypersensitivity or preceding infection.

What is Impetigo?

An acute, contagious superficial skin infection of the skin.

What is Cellulitis?

An acute, spreading infection of dermal and subcutaneous tissues

How do you classify HF (3)?

Anatomically (R vs L) Physiologically (Systolic vs diastolic) Functionally (How symptomatic is patient)

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

Ddx with chest pain?

Angina pectoris Unstable angina Prinzmetal angina Acute MI Aortic dissection Pericarditis Acute pericardial tamponade PE MSK cause (costochondritis) GI cause (PUD, gastritis) Pulm cause (PNA)

What is unstable angina?

Angina that is either new in onset or differs from a patient's typical stable angina pattern

_____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

Vascular injury to the neck can be imaged via?

Angiography or CT angiography

Zone III

Angle of the mandible to base of the skull

Tx options for MR?

Annuloplasty <---preferred tx Valve replacement - done when there is severe deformity or degeneration of valve

Anterior or posterior dislocation more common in mandibular dislocation?

Anterior

____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

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

Management of PID?

Antibiotics Antipyretics Analgesics Bed rest Removal of IUD if present Partners should be evaluated and treated

What are some common allergens that cause allergic CD?

Antibiotics Metal salts Dyes Plants Oils Nickel Latex

Tx of A.fib long term?

Anticoagulants (Warfarin, Dabigatran, etc)

What is preop management of arterial occlusion?

Anticoagulate with IV heparin Arteriogram

Stable patients in A.fib for >48 hours should be...

Anticoagulated with heparin or lovenox before cardioversion

Tx for Zoster?

Antivirals within 72 hours of outbreak - Acyclovir, valacyclovir Steroids may prevent postherpetic neuralgia Prevention with zostavax!

Unequal blood pressure in arms can indicate?

Aortic Disruption

A widened mediastinum of CXR is indicative of?

Aortic Disruption/ Rupture

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

Aortic regurgitation; "water hammer" pulses

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

Aortic stenosis; ACEi

Diagnostic studies for thoracic AA?

Aortography CT/MRI are preferred over US

_________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

What are causes of cardiogenic syncope?

Arrhythmias (V tach, SVT, sick sinus) PE Aortic stenosis Congenital abnormalities Carotid sinus hypersensitivity Heart blocks Aortic dissection

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

Arterial; Venous

Diagnostic studies for arterial occlusion?

Arteriogram (A-gram) EKG Doppler

What are the most common causes of 2ndary amenorrhea with normal estrogen?

Asherman syndrome PCOS

Who is Brugada syndrome most often seen in?

Asian men

What is the anti-inflammatory used for RF?

Aspirin is DOC for anti-inflammatory, even in kids

mnemonic for reading CXR---ABCDEGHI

Assessment of quality Bone and soft tissues Cardiac Diaphragms Effusion

What are some signs and symptoms of mitral stenosis?

Asymptomatic Mild DOE Eventually A. fib Rare due to routine PCN use Mostly seen in females

What are clinical features of an abdominal AA (AAA)?

Asymptomatic Pulsating abdominal mass Abdominal or back pain

What are clinical features of a thoracic AA?

Asymptomatic Substernal, back, neck pain Dyspnea Stridor Cough Dysphagia Hoarseness Symptoms of SVC syndrome

What are clinical features of ovarian cysts?

Asymptomatic masses Painful mass Menstrual delay Hemorrhage because of rupture

What is multifocal atrial tachycardia (MAT)?

At least 3 different sites of atrial ectopy. Most often found in elderly patients with decompensated COPD

Causes of AA? Which is most common?

Atherosclerosis <---MC cause Genetic Giant cell arteritis Vasculitis Trauma Marfan syndrome Ehlers-Danlos syndrome

Arrhythmia Types

Atrial Fibrillation Atrial Flutter PSVT Heart Block PVC, PAC, MAT Ventricular Fibrillation Ventricular Tachycardia WPW

What are you hearing in S4?

Atrial contraction ("gallop")

Tx for symptomatic junctional rhythm?

Atropine .5mg q 5min till you reach 2mg

SVT

Attempt Vagal Maneuvers Adenosine (6, 12, 12) Cardioversion

pt presented to ED after dog bite, aside from swelling asymptomatic. he needs rabies prophylaxis and some abx coverage. name the abx that should be given for him (bites on arms)

Augmentin... it's good for staph but not MRSA but low suspicion of MRSA here. Clindamycin technically works but coverage for staph is getting worse and it tears up the GI tract (C. diff)

What is an Austin Flint murmur? Quincke sign? "Water hammer" pulse?

Austin flint murmur - Reverberation of regurgitant flow Quincke sign - capillary pulsations of uvula "Water hammer" pulse - increased pulse pressure palpated over peripheral arteries Musset sign - head bobbing with each heart beat

Clay-Shoveler's fracture

Avulsion of the end of the spinous process of a lower cervical vertebrae - Stable Fracture

Where does Scabies usually distribute?

Axilla, umbilicus, groin, penis, instep of foot, web spaces, fingers, and toes In infants face and scalp can be involved

What are 1st line tx for Chlamydia?

Azithromycin 1gm PO x 1 OR Doxycycline 100mg PO BID x 7 days

BATTLE CAMP is a mnemonic for hemoptysis... spell out each letter

B=bronchiectasis or bronchitis A=aspergillous or autoimmune T=TB T=Tumor (pulmonary) L=lung abscess E=Embolus as in pulmonary embolism (has to be pretty huge) C=cystic fibrosis, coagulopathy A=AVN or diffuse alveolar hemorrhage M=Mitral valve issue particularly stenosis P=pneumonia which is the most common cause according to onlinemeded

What is the first line therapy for chronic angina?

BB

Management post-MI?

BB Statin ACE-I/ARB CCB

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

How are frequent PVCs treated?

BB/CCBs

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 does the murmur of AR sound like?

BLOWING, faint, high pitched, systolic and diastolic decrescendo murmur in the 2-4th LICS. Radiates to apex and RSB. Have patient sit, lean forward, with full exhalation.

Labs for CHF?

BNP BMP LFT CBC

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

BNP - B-type natriuretic peptide

What is happening in mitral regurgitation (MR)?

Backflow of blood in to LA (LA will get bigger) LV will get bigger to try and compensate, eventually it will fail. Very common.

bacterial vs viral meningitis spinal fluid analysis

Bacterial: (*all high but glucose low*) opening pressure > 300 mm WBC count >1000/mm3 Glucose < 40 mg/dL Protein >200 mg/dL Viral: (*all low but glucose high*) opening pressure < 300 mm WBC count < 1000/mm3 Glucose > 40 mg/dL Protein < 200 mg/dL

tx for PCP pneumonia

Bactrim IV and steroids (don't forget those steroids)

How do you manage preterm labor/delivery?

Bed rest Oral or IV hydration Antibiotics Steroids Tocolytics if indicated Cerclage if indicated

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

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

Beta Blockers

Diagnostic labs for DUB?

Beta-hCG to rule out pregnancy CBC LFTs Iron studies PT/PTT Documentation of ovulation Thyroid panel Serum progesterone Prolactin Serum FSH

Hangman's fracture

Bilateral fracture of pedicles of C2 due to hyperextension - Unstable

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 should be on your Ddx for urologic pelvic pain?

Bladder malignancy Interstitial cystitis - will have irritative voiding symptoms - UTI symptoms with negative culture. Chronic UTI Urolithiasis

#1 goal in the OR

Bleeding control

Subarachnoid hemorrhage

Bleeding into subarachnoid space between the arachnoid and the pia matter - Commonly spontaneous and atraumatic, often the result of rupture of an aneurysm or arteriovenous malformation - Pt will c/o worst headache of their life

Hypertension

Blood Pressure >140/90 Common in the ED, 33% of HTN in ED is situational, Treatment in asymptomatic patients is controversial

What are you hearing if there is an S3?

Blood rushing in the LV and hitting the wall ("gallop")

Blood and nervous supply of bladder?

Blood: Internal Iliac artery Nerve: Lumbar and sacral plexus

Flail Chest

Blunt force trauma causing chest wall injury with loss of bony continuity to the thoracic cage

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

PE signs of ACS?

Brady or tachy Hypotensive or hypertensive JVD Soft heart sounds Transient murmur of MR S4 gallop Possible bibasilar rales Low grade fever Pericardial friction rubs

Subdural Hematoma

Bridging Veins *Cresent* Venous bleed

_______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

What imaging modality would be most appropriate for lower airway injury?

Bronchoscopy

____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

What is Pericardial effusion?

Build up of fluid between the pericardium and heart. Produces a restrictive pressure on the heart. Similar pathophysiology to pleural effusion of the lungs.

____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

What are fascicular blocks?

Bundle branch blocks

A patient in VF cardiac arrest has failed to respond to defibrillation & epinephrine 1 mg IV. You give the nurse an order to administer epinephrine every 3 minutes during the code. Which of the following dose regimens is recommended? a. epinephrine 1 mg, 3 mg, 5 mg, and 7 mg (escalating regimen) b. epinephrine 0.2 mg/kg per dose (high-dose regimen) c. epinephrine 1 mg IV push, repeated every 3-5 minutes d. epinephrine 1 mg IV push, followed in 3 minutes by vasopressin 40 U IV

C

What drug-dose combination is recommended as the first line medication to give to a patient in asystole? a. epinephrine 3 mg IV b. atropine 3 mg IV c. epinephrine 1 mg of a 1:10 000 solution IV d. atropine 0.5 mg IV

C

When using vasopressin on a patient who remains in persistent VF arrest, which of the following guidelines for use of vasopressin is true? a. Give vasopressin 40 U every 3 to 5 minutes b. Give vasopressin for better vasoconstriction and ß-adrenergic; stimulation than provided by epinephrine c. Give vasopressin as an alternative to epinephrine in the first or second dose of a vasopressor agent as treatment for ventricular fibrillation d. give vasopressin as the first-line pressor agent for clinical shock caused by hypovolemia

C

Which of the below are the proper sequence of events indicated for the performance of CPR and the operation of an AED. a. Send someone to call 911, attach AED electrode pads, open the airway, turn on the AED, provide, 2 breaths, check for a pulse b. Wait for the AED and barrier device to arrive, open the airway, provide 2 breaths, check for a pulse, if no pulse attach AED electrode pads, follow AED prompts c. Check scene safety, check the patient for responsiveness, send someone to call 911, check for a pulse, if no pulse start compressions until the AED arrives then attach the AED, follow AED prompts d. Provide 2 breaths, check for a pulse, if no pulse perform chest compressions for 1 minute, call for the AED, when the AED arrives attach electrode pads

C

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

Diagnostic studies for orthostatic hypotension?

CBC BMP EKG Orthostatic vitals Tilt test if there are no findings

Diagnostic studies for pericarditis?

CBC - WBC elevated EKG - diffuse ST elevation Echo, dopper, CT, MRI may be helpful

minimal workup for all pts presenting w/ chest pain

CBC w/ diff, CXR, BMP, troponin, EKG

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

Pharm therapy for prinzmetal angina?

CCB

tx for Prinzmetal angina

CCBs

What can exacerbate sick sinus syndrome?

CCBs BB Dig Sympatholytic agents Antiarrhythmics Aerosol propellant abuse

Tx of MAT?

CCBs Mg sulfate Replete K levels

What drugs are used for rate control of A.fib?

CCBs (Diltiazem, Verapamil) Amiodarone (if EF<40%) Dig Dronedarone BB (if no heart failure)

What is the most frequent cause of hospitalization in the elderly?

CHF - 10% of patients have it after age 80

what is the one major ddx for ARDS

CHF. differentiate based on history; ARDS typically preceded by some major form of illness, namely sepsis, or some major insult such as nearly drowning. they look clinically similar--crackles on auscultation, CXR demonstrating pulmonary edema. get a BNP and ECHO, both of which will or may be normal in CHF and is definitely normal in ARDS

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

What are the most common causes of 2ndary amenorrhea in hypoestrogenic women?

CNS tumor Stress Hyperprolacinemia Hypophysitis Sheehan syndrome Premature ovarian syndrome

In which population is Klebsiella pneumonia most commonly seen in?

COPD, Alcoholics and the elderly. currant jelly sputum bulging fissures

ED management of CHF exacerbation

CPAP/BiPAP Frequent re-evaluation, cardiac monitoring Nitrates are 1st line therapy Diuretics should be reserved for volume overloaded patients Nitroprusside if there is severe HTN

____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

imaging modality of choice for a thoracic aneurysm

CT (note that that's not echo)

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

utility of imaging in suspected case of peritonsilar abscess

CT only if you absolutely must confirm the diagnosis; this tends to occur in kids and you don't want to give them CA, this is also expensive. it can be difficult to differentiate tonsilitis from peritonsilar abscess and CT (or US--less common) can be done to differentiate the two

Best imaging modality for an orbital wall fx?

CT scan

Head trauma imaging modality of choice

CT scan

Imaging modality of choice to rule out significant cervical spine injury when suspicion is high

CT scan

Most specific scan for injury in blunt abdominal trauma?

CT scan

Primary diagnostic modality for observation of non-surgical abdominal trauma?

CT scan

____ is the procedure of choice for imaging pts with microscopic hematuria, history of shock, or sudden deceleration injury

CT scan

71yo male presents to ED for sudden onset blurry vision (reports seeing things in strange colors). has been drinking, bumped head last night; per son pt isn't acting like himself and speech is slurred (has been drinking). pt has hx of TIA, MI, smoking. PE reveals double vision which persists w/ one eye closed, slurred speech, otherwise unremarkable. what do you do?

CT w/o contrast to check for (hemorhaggic) stroke. this patient was also on blood thinners and therefore less likely to have ischemic. double vision is not concerning unless it persists w/ one eye closed in which cause it suggests a cerebral tumor of some sort. this patient was on blood thinners, which makes hemorrhagic more concerning, also rules out the possibility of using TPA. be sure to keep hypoglycemia in the ddx for altered MS (this guy had a BS of 68).

Modality of choice to image kidney in a trauma situation?

CT with IV contrast

some of the goals of therapy for the tx of sepsis syndrome are CVP, urinary output, MAP, central venous saturation... what are the values for each of these and what do they indicate?

CVP 10-12, urinary output of at least 0.5cc/kg/hr, MAP at least 65 to correct hypotension, central venous sat of at least 70% achieved w/ lots of fluid, BS abx (narrow if you know the infx), control infx sites (remove central lines), pressors, steroids

Dx of Rib Fx

CXR

Diagnostic tests for CHF? Which is the best test?

CXR EKG Echo <---best

Diagnostic tests for aortic dissection?

CXR - widened mediastinum, pleural effusion TEE CTA Aortography - gold standard (but not often done)

Clinical features of PACs

Can occur at any age, often in absence of heart disease May feel like palpitations or "fluttering" in the chest

What causes Vulvovaginal candidiasis?

Candida albicans Not an STI!

How does ventilation differ with cardiac arrest vs respiratory arrest?

Cardiac arrest: Give 1 ventilation every 6-8 seconds (8-10 breaths per min) Respiratory arrest: Give 1 ventilation every 5-6 seconds (10-12 breaths per min)

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

Cardiac tamponade

How is pericardial effusion different from cardiac tamponade?

Cardiac tamponade is where there is a pericardial effusion that causes a significant degree of compression of the heart resulting in decreased blood being pumped around the body.

_____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

How do you treat urticaria?

Cause should be eliminated H1 antihistamine administered (Diphenhydramine, Hydroxyzine, fexofenadine, cetirizine) H2 antihistamine (famotidine or ranitidine) if not responsive to H1. Give EpiPen if there is concern for anaphylaxis

What is a transudative pleural effusion cause by?

Caused by SYSTEMIC hydrostatic or oncotic pressure imbalances, usually CHF

What causes a pericardial effusion?

Caused by pericarditis, lung cancer, uremia, trauma

what can cause cavitary lung lesions - generally speaking

Cavitary lesions of the lung have multiple causes, including both infectious and non-infectious etiologies. These include bacterial pneumonia, fungal disease, tuberculosis, malignancies and some pulmonary vascular disease.

What are 1st line antibiotics for treatment of Gonorrhea?

Ceftriaxone (IM) + Azithromycin (PO) x 1 OR Doxycycline 100mg PO BID x 7 days

What are recommended outpatient antibiotic regimens for treatment of PID? How long is duration of therapy?

Ceftriaxone (IM) + Doxy with or without Metronidazole OR Cefoxitin (IM) + Probenecid + Doxy with or without Metronidazole *Total duration of treatment will still be 14 days

____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

This type of brain herniation causes pinpoint pupils and increased muscle tone and my progress to hyperventilation and decorticate posturing

Central Transtentorial herniation

____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

Cerebellotonsillar herniation

Cerebellar tonsils herniate through the foramen magnum - Pts deteriorate quickly to flaccid paralysis and death

CVA

Cerebral ischemia/infaction Occlusive vs. Hemorrhagic HTN, atherosclerosis, DM, lipids, smoking, family hx, estrogen, trauma, Arteriovenous Malformations, aneurysms, tumors TIA(symptoms resolve in 24 hours)- 33% have CVA within 5 years

Non operative spinal stabilization may be achieved by?

Cervical orthoses

What is the pathway of ascending infection that leads to PID?

Cervicitis-->Endometritis-->Salpingitis/oophoritis/tuboovarian abscess--->Peritonitis

What are common signs of pregnancy? (9)

Chadwick sign Increased basal body temp Skin changes (melasma, linea nigra) +Preg test Hegar sign (softening of uterus) Uterine growth Fetal heart tones Palpation of fetus U/S of fetus

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

What are some pathologic changes of the heart that cause CHF?

Changes of myocardial contractility Structural integrity of the valves Preload or afterload of ventricle Changes in heart rate

What are characteristics of third degree burns?

Charred, pearly white Hallmark: Painless because of destroyed skin layer and nerve endings Most common cause: Grease, steam, flame, high voltage

What are systemic signs/symptoms of Erysipelas?

Chills Fever HA Joint pain

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

_____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

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 are clinical features of Scarlet fever?

Classic symptoms: SANDPAPER rash in groin, axilla with DESQUAMATION (peeling) after 3-4 days. Strep symptoms: Pharyngitis, fever Bright red tongue with a "STRAWBERRY" appearance

What are symptoms of PAD?

Claudication which is relieved by rest <--- 1st symptom Ischemia Pain with exercise Late disease: skin ulceration, gangrene, loss of limb

What is the "non-classical" appearance of endometriosis?

Clear vesicles White spots Yellow spots Nodules "Pockets" - circular folds Normal tissue - may need microscope to see

What is Levine sign?

Clenched fist and teeth to describe classic anginal pain

Diagnosis of abruptio placentae?

Clinical diagnosis

Diagnostic studies for Varicella-zoster?

Clinical diagnosis

Dx of Chlamydia?

Clinical diagnosis Gram stain Complement fixation test of immunofluorescence, ELISA, DNA probes

How do you diagnose VVC?

Clinical symptoms Normal pH Whiff test - negative KOH - positive Wet prep - budding yeast forms or mycelia are seen

What is Pelvic inflammatory disease (PID)?

Clinical syndrome associated with ascending spread of microorganisms from the vagina or cervix to the endometrium, fallopian tubes, ovaries, and contiguous structures.

All pts with testicular trauma should be imaged how?

Color doppler ultrasound

What is Bacterial Vaginosis?

Common infection and recurrent cause of abnormal vaginal discharge in women of childbearing age. Caused by overgrowth of Gardnerella and other anaerobes. Not an STI.

Clinical features of lice?

Concentrate on waist, shoulders, axillae, and neck Bites produce red spots that progress to papules and wheals Intensely pruritic White ova adhere to hair shaft

Head Injuries

Concussion: Repetitive questioning, brief LOC Skull Fracture: Battle sign (bruising of mastoid process), Raccoon's eyes, Cerebrospinal fluid leak, blood in EAC EDH, SDH, ICH: Seizure, Altered Mental Status, Pain, Focal Deficits In the elderly, clinical acumen cannot reliably exclude significant injury

What is endometriosis?

Condition where there is endometrial tissue found outside the endometrial cavity

What are two ways to surgically treat endometriosis?

Conservative or definitive treatment (hysterectomy). Conservative surgery involves lysing adhesions and removing endometriosis to restore the anatomy though use of laparoscopy.

Head injuries Treatments

Consider transfer to traumacenter Neurosurgical consult Hyperventilation controversial, Airway protection for GCS <8 or rapid decline Mannitol/Hypertonic saline for ICP Burr hole Correct platelets, coagulopathy Avoid hypotension/hypoxia

Injury to the spinothalamic tract causes?

Contralateral pain and temperature sensation loss 2 levels below the lesion

In a Tension Pneumothorax the trachea deviates to which side?

Contralateral side

____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)

_____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)

What is the definitive diagnosis for angina?

Coronary angiogram

What is the definitive diagnostic procedure for ACS?

Coronary angiography

What tracts are located anteriorly within the spinal cord?

Corticospinal and spinothalamic tracts

What tracts are located on the anterior part of the spinal cord?

Corticospinal and spinothalamic tracts

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

Creatine kinase Mb

barking cough in a kid is characteristic of which infection?

Croup

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

Cushing triad

Tx for PACs?

D/c precipitating drugs Treat underlying disorders Metoprolol if there are significant symptoms

MAP

DBP + (SBP - DBP)

Appendicitis Work-up and Treatment

DDx: PID, gonadal torsion, acute gastroenteritis, diverticulitis, UTI, kidney stone, ectopic pregnancy IV, pain control, NPO, fluids CBC, UA, BMPm GC/Chlamydia, hCG CT or ultrasound Surgical Consult +/- Antibiotics

Management of abruptio placentae?

DELIVERY of fetus and placenta is definitive tx (however depends on status of fetus and degree of separation) Blood type, cross-match, coag studies Insertion of large bore IV C-section is preferred route of delivery

hyper or hypoglycemia w/ altered mental status in a diabetic patient is what condition until proven otherwise?

DKA or HHS

minimally three conditions/classes of medicatinos that may suggest pancreatitis for epigastric pain

DM, alcohol, glucocorticoids

Diagnostic studies for PID?

DNA probes for G&C TV ultrasound Culdocentesis or laparoscopy

76yo female presents w/ complaint of SOB. upon further questioning, you decided that it is DOE. physical exam reveals bilateral 2+ pitting edema of lower extremities, hepatosplenomegaly, JVD. what is your leading diagnosis? what will the work up entail? the tx?

DOE should make you think of HF; this can occur in left or right, but other ssx of JVD, peripheral edema, hepatosplenomegaly suggest right heart failure. Now the workup progresses to an ECHO to determine if it is systolic, diastolic or both; this will also give an ejection fraction value, which if less than 35% requires an AICD. Everyone with heart failure gets minimally ACEI and BB, most will also get a diuretic (typically initially furosemide, may also add spironolactone). workup will prolly also include a BNP, EKG, CBC w/ diff Every patient w/ HF also requires a fluid and Na restricted diet (no more than 2L/day fluid, no more than 2g/day Na)

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

DPL - diagnostic peritoneal lavage

Advantage of DPL over FAST scan?

DPL definitively identifies blood, while FAST scan cannot discriminate between blood and fluid

What is the difference between dysfunctional uterine bleeding (DUB) and abnormal uterine bleeding (AUB)?

DUB has no anatomic lesion whereas AUB is "bleeding for a reason"

the Well's criteria can be used to predict whether or not a person has a PE, much like the PERC score; what is the Well's criteria

DVT sx (unilateral leg swelling, erythma, warmth) gets 3 pts, leading dx PE gets 3 pts, tachycardia (>100bpm) gets 1.5 pts, immobilized for more than 3 days (or?) surgery w/in past 4 weeks gets 1.5 pts, hemoptysis gets 1 pt, CA gets 1 pt PE likely if they have more than 4, unlikely if less than 4 pts

______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

What are characteristics of fourth degree burn?

Damage to fascia, muscle, bone Tissue is necrotic Most common causes: Hot and heavy objects (molten metal, extended exposure, electrical injuries)

What are the two classes of aortic dissection?

Debakey Stanford

Clinical features of hemorrhagic shock?

Decrease in BP Narrow pulse pressure Tachycardia Dilation of pupils

Vfib

Defibrillation is most important ACLS pulseless and unconscious

How are symptoms and the extent of endometriosis related?

Degree of endometriosis does not correlate with symptoms. Pain is more related to the depth of disease.

What is premature delivery?

Delivery of a viable infant before 37 weeks. Occurs in 8-10% of births. Most common cause of neonatal death not resulting from a congenital cause.

What is the clinical significance of an arrhythmia?

Depends how much it impairs cardiac output or how likely it is to deteriorate in to a more serious disturbance

How do you treat cellulitis?

Depends on severity: PCN Cephalosporins Augmentin If MRSA - use TMP-SMX (Clinda or Doxy if allergic to sulfa)

Management of DUB?

Depends on underlying cause If there is severe bleeding can do iron therapy, volume replacement, IV or oral high dose estrogens Progestin trial OCPs Cyclic protestins (in young patients) D&C Refractory cases may require endometrial ablation or hysterectomy

What are some "other" possible causes of chronic pelvic pain?

Depression Somatization disorder Celiac disease Neurologic dysfunction Shingles Prophyria Familial Mediterranean Fever

Clinical features of anaphlaxis?

Dermatologic: pruritis, flushing, urticaria, erythema multiforme, angioedema Respiratory: SOB, wheezing, cough, stridor, rhinorrhea Cardiovascular: Dysrhythmias, collapse, arrest GI: Cramping, N/V GU: Urgency, cramping Eye: Tearing, pruritis, redness

Aortic disruption most commonly involves?

Descending aorta

Corticospinal tract

Descending motor tract - Damage to it results in ipsilateral muscle weakness, spasticity and paralysis

_____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)

What kind of murmurs are always pathologic?

Diastolic

What will the EKG show with pericarditis?

Diffuse ST elevation without reciprocal changes or PR depression

Pericarditis EKG

Diffuse ST segment elevation-upward curves (smile) p-r depression

What are signs/symptoms of Trichomoniasis?

Diffuse malodorous yellow-green vaginal discharge with vulvar irritation Vaginal pH>4.5 Colpitis macularis (Strawberry cervix) Many women are asymptomatic

What should you avoid with PROM?

Digital exam

What is contraindicated with placenta previa?

Digital exam - can cause hemorrhage

What are signs/symptoms of cervicitis?

Discharge which is yellow or green +/- odor Friable, quick to bleed cervix Can progress to PID if untreated

Classification of arrhythmias?

Disorders of impulse formation or automaticity Abnormalities of conduction, reentry, and triggered activity

Diffuse axonal injury

Disruption of the axonal fibers in the white matter and brainstem - Blurring of the grey and white matter margins, punctate hemorrhages and cerebral edema are seen

what is the tx for menieres?

Diuretics -Low salt diet -Anti-vertigo meds

What do you need to do if a patient is on a GnRH agonist for >6 months?

Do add back therapy - give low dose OCP or medroxyprogesterone to replete hormones.

Antiarrhythmic therapy in patients with chronic A flutter?

Dofetilide is DOC

Most common rupture point in bladder?

Dome

name the ONE technique/image to check for suspected testicular torsion

Doppler US (emphasis here on the doppler; I knew it was US but didn't know the flavor)

Diagnostic studies for PAD? What is the gold standard?

Doppler ultrasound Ankle-brachial index (ABI) - uses Doppler measures to compare BP in upper and lower extremities. <0.9 indicates disease Angiography <----gold standard CT/MRI Elevated homocysteine

Drug Hypersensitivity Syndrome

Drug reaction occurring in the first 2 months after initiation of drug Morbilliform drug eruption, facial edema Symmetric distribution trunk/extremities

Fixed Drug Eruption

Drug rxn occuring in solitary erythematous patch, plaque, erosion, or bullae Upon rechallenge still breaks out at same site

What are causes of secondary amenorrhea besides pregnancy?

Drug use Stress Significant weight change Excessive exercise

What are characteristics of allergic contact dermatitis?

Due to type IV cell mediated or delayed hypersensitivity reaction Must be sensitized to offending agent Can spread beyond contact area or generalize Signs: Erythema, papules, vesicle, erosions, crusts, scales Occurs within 12-72 hours LINEAR FORMATIONS

Clinical features of thrombophlebitis/DVT?

Dull pain Erythema Tenderness Induration of involved vein Swelling of involved area with heat and redness Homan's sign (unreliable)

How is an acute asthma exacerbation treated?

Duoneb tx (albuterol + ipratropium) q 20 minutes x 3

DVT Diagnosis

Duplex US (if negative, follow up US in 3-5 days) Impedance Plethysmography Venography MRI DDimer Well's Criteria

Diagnostic test for DVT?

Duplex ultrasound <---preferred study Venography <--- most accurate study D-dimer (neg is <500) Angiography if PE is suspected

How is VVC diagnosed? Treatment?

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

PE Diagnosis and Treatment

Dx: Well's Criteria (risk factors), Ddimer, Doppler US, PERC Rule, CTA, VQ Scan Tx: Heparin (quick on/off) vs. LMWH (easier to give) Thrombolytics (Saddle PE, admit to ICU) Embolectomy

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

atrial septal defect Dx

ECHO is diagnostic

coarctation of the aorta Dx

ECHO is diagnostic diagnosis also made by PE confirmed by 4-extremity blood pressures

ventricular septal defect Dx

ECHO is diagnostic EKG: LVH or BVH with tall R in V5, V6 and deep Q wave

hypertrophic cardiomyopathy Dx

ECHO w/ ventricular septal thickening > 15 mm

how do you distinguish systolic from diastolic heart failure?

ECHO. diastolic is aka HF w/ preserved EF

indication for an Automated Implanted Cardio Defibrilator (AICD) in heart failure patients

EF of less than 35%

what is THE first thing that needs to be ordered for a pt presenting w/ chest pain decided to be angina?

EKG

Work up for chest pain? Which test is most reliable?

EKG <---most reliable Cardiac markers Echo Stress test

tetralogy of fallot Dx

EKG > RAD, RVH CXR-boot shaped heart

What are differentiating factors between EM and SJS or TEN?

EM: Occurs in young males Frequent recurrences Less fever Milder mucosal lesions No association with a collagen vascular disease, HIV, or cancer

SJS is thought to be a severe variant of ___. TEN is thought to be a severe variant of ___.

EM; SJS

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

Prevention of chronic venous insufficiency?

Early aggressive treatment of venous reflux states: (acute thrombophlepbitis, varicose veins, use of compression hose, weight reduction)

How do you treat third degree burns?

Early excision of eschar STSG autograft (split thickness skin graft)

When is an AMI most likely to present?

Early morning because of surge of catecholamines

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

Diagnostic studies and findings with cardiac tamponade

Echo CXR - water bottle heart shape EKG - electrical alternans

What is the definitive method for diagnosing heart murmurs?

Echo (particularly transesophageal) Cardiac cath

Diagnostic studies for endocarditis?

Echo - key! Helps identify valve involved CXR EKG

What should be on your DDx with vaginal bleeding and a positive pregnancy test?

Ectopic pregnancy Spontaneous abortion Placental abruption Placenta previa Post-partum hemorrhage

What populations present with atypical chest pain or no chest pain when having an AMI?

Elderly Diabetics Women Patient with psych d/o

What is the classic patient to have an AA?

Elderly male smoker with CAD, emphysema, and renal impairment

What factors increase incidence of arrhythmias?

Electrolyte imbalances Hormonal imbalances Hypoxia Drug effects MI

Prevention for DVT?

Elevation of foot of bed Leg exercises Compression hose SCDs Anticoagulation if high risk (enoxaparin or unfractionated heparin followed by warfarin) <---preferred method

Treatment of chronic venous insufficiency?

Elevation of legs Avoidance of extended sitting/standing Compression hose Stasis ulcers: wet compresses, hydrocortisone cream, skin grafting

Blood coming from the tooth indicated what type of fx?

Ellis III

Topical Analgesics should not be used on what type of ellis fracture?

Ellis type III

_____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

How do you treat endocarditis?

Empiric antibiotic tx (Gentamicin with Ceftriaxone OR Vancomycin) THEN adjust therapy once blood cultures come back Valve replacement if infection does not resolve

____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

What are women who don't menstruate in the presence of estrogen production at risk for?

Endometrial cancer - lining keeps building up which can lead to atypical cells

____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

What are causes of secondary dysmenorrhea?

Endometriosis Adenomyosis Uterine fibroids PID IUD

What should be on your Ddx for gynecologic pelvic pain?

Endometriosis Gynecologic malignancies PID Pelvic adhesions Adenomyosis Chronic endometritis Symptomatic pelvic relaxation (prolapse pain)

Diplopia on upward gaze indicates?

Entrapment of the rectus muscle

What do you give after 3 cycles of CPR/defibrillation if patient still doesn't have a pulse?

Epi or vasopressin

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

Epidural

What type of brain injury is characterized by loss of consciousness followed by a lucid interval?

Epidural Hematoma

Blunt trauma to the temporal or temporoparietal area can result in?

Epidural hematoma

_____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

what test can be done to differentiate Prinzmetal angina from true angina?

Ergonovine challenge

____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

How do you tell the difference between Erysipelas and Cellulitis?

Erysipelas is superficial, raised, well-defined borders Cellulitis is deep, flat, and has poorly defined margins

Desquamation disease

Erythema multiforme minor (EM) Erythema multiforme major (Includes SJS, TEN)

Preferred sedation med in rapid sequence intubation?

Etomidate (Doesn't drop BP)

Tetanus is mandated in all burn patients except for when?

Except those immunized within the past 12 months

Non-pharm therapy for CHF?

Exercise Low Na Diet Smoking and alcohol cessation Stress reduction Daily weight monitoring Cardiac rehab

What is the most useful and cost effective noninvasive test for angina?

Exercise stress testing

What are clinical features of left sided heart failure?

Exertional pulmonary vascular congestion Exertional dyspnea + cough Fatigue Orthopnea Paroxysmal nocturnal dyspnea Basilar rales Gallops Exercise intolerance

How do you manage PPROM?

Expectant management if mother and baby are stable. Mother should be hospitalized and be on strict bed rest Betamethasone should be given if <34 weeks Abx to prevent infection NST and BPP daily to monitor fetal well being Amniocentesis to check for lung maturity Delivery if there is maternal or fetal distress

How do you manage PROM after 37 weeks?

Expectant management if patient is stable If delivery needs to be expedited, induction of labor with prostaglandin cervical gel or oxytocin is indicated

What is adenomyositis?

Extension of endometrial glands into the uterine musculature

What are 2 common types of abruption? Which is more common? Which is more severe?

External abruption - more common Concealed abruption - more severe

Flexion teardrop fracture

Extreme flexion causes a fracture of the anteroinferior portion of the vertebral body. - Highly unstable because they are associated with disruption of the ligamentous structure at the level of injury

T/F? genotype positive-phenotype negative for HCM is a disqualificaiton criteria for most competitive sports

F no evidence yet, but clinical diagnosis of HCM is a disqualification criteria

T/F Loss of consciousness is a defining characteristic of a concussion

FALSE

T/F magnitude of hematuria correlates with magnitude of injury

FALSE

T/F Succinylcholine is appropriate to use in a burn pt

FALSE (causes Hyperkalemia in an already hyperkalemic Pt)

T/F Mild TBI results in a predominantly structural insult

FALSE, It is a predominantly metabolic insult

Diagnostic modality of choice for "tripod fracture"

Facial CT scan

Imaging test of choice for maxillary trauma?

Facial CT scan

Virchow's triad consists of venous stasis, endothelial damage, and hypercoagulable state; name some hypercoagulable states

Factor V Leiden, Protein C and S deficiencies, antiphospholipid syndrome, pregnancy, CA

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

Shock Definition and Types

Failure to adequately deliver blood, oxygen, or nutrients to tissue to meet metabolic demands 1. Hypovolemic (not enough blood) 2. Cardiogenic (heart is not working well enough) 3. Distributive (Sepsis, anaphylaxis, cord injury) 4. Obstructive (PE, Tamponade)

Most common injury related to trauma?

Fall

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

What drugs are used for chemical conversion of A.fib?

Flecainide Propafenone Amiodarone - DOC Dronedarone Ibutilide

Simple wedge fracture

Flexion and compression causes fracture of the anterior vertebral body between two other vertebral bodies - Stable fracture unless there is significant posterior ligamentous disruption

How do you treat Impetigo?

For Non-bullous: 2% Mupirocin and oral antibiotics For Bullous: Oral abx (can return to school after being on abx for 24 hours)

When is PCI indicated?

For STEMI within 90 minutes of symptoms

Parkland formula

Formula widely used to estimate the volume of crystalloid necessary for initial resuscitation of burn patient: 3-4cc of LR x Kg x BSA 1/2 given in first 8 hours Last 1/2 given over 16 hours

Jefferson Fracture

Fracture of C1 (atlas) caused by a compressive downward force from the occipital condyles

Odontoid fracture

Fracture of the dens of C2 - Type II and III are unstable and these may present with neurologic impairment

Le fort Fracture

Fracture of the maxilla. (There are different types of Le Fort fractures; they are dictated "Le Fort 1, 2, or 3" and are transcribed as Le Fort I, Le Fort II, and Le Fort III.)

Open skull fracture

Fracture of the skull with an overlying laceration or open wound

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

Frank-Starling principle

What are clinical features of EM?

Frequent recurrences Lesions begin as macules and become papular. Then vesicles and bullae form in the center of he papules. Targetoid IRIS lesions are characteristic. Typically occurs on extremities MUCOSAL LESIONS that are painful and erode.

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

What causes erysipelas?

GAS

Mild TBI

GCS 14-15

Severe TBI

GCS 3-8

Moderate TBI

GCS 9-13

name four common (in my opinion) causes of chest pain in a relatively young patient (i.e. not ischemic)

GERD, Prinzmetal, pericarditis, costochondritis

____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

What causes Aortic Stenosis (AS)?

Genetic - due to a unicuspid or bicisupid valve CAD - due to a calcified/degenerative valve. MOST COMMON VALVULAR DISEASE in the US.

What is Brugada syndrome?

Genetic disorder that causes syncope, v.fib, and sudden death often during sleep Characterized by RBBB, J point elevation, saddle shaped or sloped ST segment

How do you mange a stable and non-pregnant patient with vaginal bleeding?

Get a good history Pelvic exam Labs - CBC, CMP, TSH, PT/PTT, UA, T&S U/S - if there is pain Iron supplementation If post-menopausal, have them follow up with GYN

What is the first thing you should in a patient with a suspected pregnancy?

Get a urine pregnancy test (hCG) - accurate after a woman has missed her period

What do you do if the LMP is unknown?

Get an U/S

What happens with AS when you squat?

Gets louder because squatting increases blood flow to the heart. Decreases with Valsalva (which decreases blood flow).

______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

A therapeutic trial of what may help symptoms of endometriosis? What is the downside of this?

GnRH agonist (Depo-Lupron) which inhibits the pituitary release of FSH/LH. Can only use for 6 months because it decreases bone mineral density and makes you feel like you're in menopause (hot flashes, decreased bone mineral density)

What are the 4 most common causes of primary amenorrhea?

Gonadal dysgenesis (Turner syndrome) Hypothalamic-pituitary insufficiency Androgen insensitivity Imperforate hymen

What are causes of cervicitis?

Gonorrhea Chlamydia Herpes simplex HPV

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

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

How do you diagnose BV?

Gram stain - gold standard Whiff test - positive KOH - negative

Diagnostic studies for Gonorrhea?

Gram stain of urethral discharge with culture

Never do a pelvic exam in which patients?

Gravid female >20 weeks with bleeding

What is Urticaria?

Group of disorders that have many causes. Most common causes include food or drug allergies, heat/cold, stress, infection.

_____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 are clinical features of PROM?

Gush or persistent leakage of fluid from vagina or vaginal discharge PE shows pooling of fluid

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

What organisms cause acute epiglotitis?

H. flu, Strep pneumo or Strep pyogenes, Staph aureus

general indication for fioricet

HA

What does the murmur of AS sound like?

HARSH, SYSTOLIC, crecendo-decrecendo heard best at URSB and radiates to carotid and LSB. Heard with patient sitting and leaning forward.

chlorthalidone is aka

HCTZ

Syncope

HEAD, HEART, VESSLS (mnemonic) HEAD- Hypoglycemia/hypoxia, Epilepsy, Anxiety, Dysfunction of brain stem HEART- Heart attack, Embolism of pulmonary artery, Aortic obstruction, Rhythm disturbance, Tachycardia (vtach) VESSLS- Vasovagal, Ectopic pregnancy, Situational, Carotid Sinus sensitivity, Low SVR (hypotension), Subclavial steal *Check blood glucose*

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

diagnosis of pneumothorax

HPI may or may not be contributory as a spontaneous pneumothorax may not have a remarkable hx. suspicion is raised based on oxygen sat (good positive predictive value, not negative), or sinus tachycardia. order a CXR which will typically be sufficient; if it is negative but clinical suspicion remains give em' a CT

What is the principal risk factors for EM?

HSV infection!! Previous history of EM

What is the MC cause of aortic dissection?

HTN

if there is ONE major risk factor for an aortic dissection, it is this

HTN (not HLD)

What is malignant HTN?

HTN with signs of acute end-organ damage 220/140

What causes pilonidal disease?

Hair Sitting Friction Tight clothes Obesity Local tumor Poor hygiene

What is the Rule of 9's?

Head and neck - 9% Each arm - 9% Each leg - 18% Anterior trunk - 18% Posterior trunk - 18% Perineum - 1%

What is a murmur?

Hearing blood move past a valve in a way it's not supposed to due to increased blood flow, stenosis, or regurgitation.

What are souces of emboli for arterial occlusions?

Heart (Afib) Aneurysms Atheromatous plaque

What is Congestive heart failure (CHF)?

Heart failure is a condition that occurs when the heart cannot pump or fill with enough blood due to pathologic changes in the heart. The heart must work harder to deliver blood to the body.

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

What is the Modified Duke Criteria?

Helps establish the diagnosis of infective endocarditis. Patients must have either 2 major, 1 major and 3 minor, or 5 minor criteria to be diagnosed

Most common cause of Hypovolemic shock?

Hemorrhage

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

DVT Treatment

Heparin or LMWH Thrombolysis (role unclear) Inpatient vs home care IVC filter (failed heparin or LMWH, contraindication to anticoagulation, breakthrough DVT)

Which Hepatitis can become chronic?

Hepatitis B, C, D

What are clinical features of TEN?

High fever +Nikolsky sign (epidermis detaches with rubbing) Diffuse erythema Necrotic epidermis Sheetlike loss of epidermis High mortality

Aortic aneurysm workup and treatment

High suspicion(non-urgent, urgent, emergent) US vs CT, 2 large bore IV's, Type and Cross 6-10 units PRBC, BP control, don't over resuscitate Surgical Consult- 3.5-4 cm needs consult and further work up

What are clinical features of Roseola?

High, abrupt FEVER--->febrile seizures. Fever lasts 3-7 days. Rash on face, neck, arms, legs (pinkish-red flat or raised rash which turn white when touched) Defervescence (fever goes away) occurs before rash appears

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

Homan's

What is the most sensitive clinical sign of angina on an EKG?

Horizontal or down sloping ST segment depression

correction

Howell-Jolly bodies, not Ab

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

___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

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

Clinical features of cardiogenic shock?

Hypotension Increase in JVP secondary to poor emptying of heart and systolic failure

Clinical features of neurogenic shock?

Hypotension without reflex tachycardia because there is a disconnect between the brain and cardiovascular system

Neurogenic shock

Hypotensive situation resulting from the loss of sympathetic control of vital functions from the brain. Happens with pt with injury above the 6th thoracic vertebra. - Loss of sympathetic tone below the level of injury

What are causes of orthostatic hypotension?

Hypovolemia Dehydration Meds (Diuretics) Endocrine, neurologic, metabolic disorders

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

Most important clinical sign in Pulmonary contusion or Hematoma?

Hypoxia

Should Clinical Indications

Hyptension,Cyanosis, Altered mental status, end organ dysfunction, lactate elevation

What are the stages of endometriosis?

I - Presentation of 2-3 superficial implants II - Appearance of one or more implants that occur within deeper layers of the tissue III - Many deep implants with small endometriomas on one or both ovaries. May also have filmy adhesions IV - Deep implants, large endometriomas, dense adhesions

What is Debakey I, II, III?

I - involves ascending and descending aorta II - involves ascending aorta only III - Involves descending aorta only

What are the four stages of decubitus ulcers?

I - non-blanching erythema II - Necrosis, superficial or partial thickness involving the epidermis and dermis III - Deep necrosis with full-thickness skin loss IV - Full-thickness ulceration with extensive damage and necrosis of muscle, bone, and supporting structures

abscess tx

I and D followed by Bacitracin

learning scenario: 2yo female presents w/ abdominal pain, has a hx of GERD that hasn't been well managed despite multiple different PPIs and H2 blockers. Pediatric gastroenterologist recently tried to change one out for another in hopes of controlling reflux, now pt has abdominal pain that is persisting despite medical tx (abnormal for pt). denies other ssx including n/v/d/c, fevers, chills.

I had tunnel vision and thought this was due to changing medical mgmt recently. don't forget about ddx, in this case minimally includes appendicitis, intussusception, Meckel's diverticulum. CBC would raise suspicion for appendicitis, US more telling and could be done to move over to colon and look for intussusception (currant jelly stool is just a board question, not applicable to real life)

heart murmurs are graded on a scale of I-VI, such as II/VI systolic decrescendo murmur heard at the ULSB... describe how each of these grades is established

I--heard, but super faint such that you're not entirely positive that it's there II-faint but it's definitely there (immediately identifiable) III--moderately loud IV--loud and associated w/ a palpable thrill V--very loud but can't be heard w/o a stethoscope VI--loudest and can be heard w/o a stethescope these earlier stages are fairly subjective

What should not be used during an acute asthma exac.?

ICS

Initial tx for ACS?

IV access + telemetry + MONA: Morphine Oxygen Nitro ASA

What are risk factors for infective endocarditis? Which organisms are responsible?

IV drug user (staph aureus is most common cause) Prosthetic valve (staph aureus, Gram neg, fungi) Regurgitant cardiac defect which provides a nidus for development of vegetation Infection from procedure (bacteremia)

Pericarditis work-up and Treatment

IV, monitor, pain control EKG CXR CBC, BMP, ESR, Trop(4-6 hours after onset of chest pain), +/- blood cultures Tx: Anti-inflammatory agent,Cardiology consult

Cholecystitis Treatment

IV, pain control, NPO DDx: Pancreatitis, hepatitis, PUD, renal lithiasis, AMI, PE CBC, CMP, lipase, UA Ultra Sound Outpatient surgical consult for most cholelithiasis Admission for cholecystitis- medicine vs surgery

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

kawasaki disease Tx

IVIG high dose aspirin steroids (if IVIG unresponsive)

Management for ovarian cysts?

If <8cm, follow for one or two cycles in premenopausal women If large or persistent, laparoscopy is warranted

What does a progestin trial tell you?

If bleeding stops, anovulatory cycles are confirmed

How do you manage spontaneous abortion?

If pregnancy is early the patient can be managed expectantly with careful f/u, hCG titers, and TVUS to make sure abortion proceeds to completion Misoprostol (Cytotec) D&C - to ensure complete emptying of uterus Immunoglobulin should be given to Rh negative women If abortion is septic - evacuation of uterus, medical support, and antibiotics

When should you not insert a foley catheter?

If there is blood at the meatus

Tx of cardiac tamponade?

If there is hemodynamic compromise, a pericardiocentesis is necessary to relieve fluid accumulation. NSAIDs - if due to pericarditis Abx - if infectious

When do you chemically convert A.fib?

If they have been in A.fib <48 hours

Tx of scalp laceration

If underlying skull and intracranial injury is ruled out, simple closure may be performed - Staples,sutures and tissue adhesive are all acceptable closure methods

Drug Induced Urticaria

IgE mediated-after sensitiziation occurs 7-14 days, if previously sensitized can occur in minutes Immune complex mediated - 7-10 days to react, up to 28 days NSAIDs - After drug administration 20-30 min

What is the pathophysiology of urticaria?

IgE mediated. Caused by release of histamines, bradykinen, kallikrein, and other vasoactive substances from mast cells and basophils in the skin. Causes small blood vessels to leak and results in intradermal edema.

What are outbreaks of shingles precipitated by?

Illness Stress Advancing age

When should aspirin or clopidogrel be used in a patient with a STEMI?

Immediately

Anterior cord damage results in?

Impairment and loss of motor function, pain and temperature sensation below the level of the lesion

What is intermittent claudication?

Impairment in walking, or pain, discomfort or tiredness in the legs that occurs during walking and is relieved by rest. The perceived level of pain from claudication can be mild to extremely severe. Claudication is most common in the calves but it can also affect the feet, thighs, hips, buttocks, or arms. MC caused by PAD.

____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 indicated when EF is <35

Implantable defibrillator

What is Ectopic pregnancy (EP)?

Implantation of a pregnancy anywhere but the endometrium

What is a junctional rhythm?

Impulses are generated by the AV node and go retrogradely in to the atria Occurs in patients with sinus brady, SA node exit block, or AV block There is no P wave (masked by QRS) or inverted P wave BPM is 40-60

When is defibrillation indicated?

In a pulseless patient with a shockable rhythm (like V.fib)

Clinical features of Chlamydia?

In males - watery discharge which is less painful than Gonorrhea. In females - asymptomatic, cervicitis, salpingitis, PID

Where do most EPs occur?

In the fallopian tubes (95%). 55% of these occur in the ampulla of the tubes. Due to lack of sub-mucosal layer in the fallopian tubes.

When would you want to admit a patient with PID?

Inability to exclude surgical emergency Pregnancy Does not respond to oral antibiotics Unable to tolerate oral regimen Severe illness Tubo-ovarian abscess HIV infection Immunocompromised

Definition of Shock

Inadequate tissue perfusion

What are US findings of a non-viable pregnancy?

Inappropriate development and growth Poorly formed or unformed fetal pole Fetal demise

Epinephrine indications? MOA?

Indicated in cardiac arrest. Also for profound bradycardia and hypotension as a drip. MOA: Vasopressor. Increases heart rate, contractility, and peripheral vascular resistance.

What is the major risk for PROM and PPROM?

Infection (chorioamnionitis and endometritis). This risk increases with time and hastens delivery. Cord prolapse

What is Erysipelas?

Infection involving the superficial dermal lymphatics

Which EKG leads exhibit changes with an inferior MI? Posterior? Anteroseptal? Anterior? Anterolateral?

Inferior - II, III, aVF Posterior - V1, V2 Anteroseptal - V1, V2 Anterior - V1-V3 Anterolateral - V4-6

ST Elevations in II, III, aVF

Inferior MI; right coronary artery

Zone II

Inferior cricoid cartilage to the angle of the mandible

Pericarditis

Inflammation of pericardium Cause: Idiopathic, viral, malignant, Dressler's S/Sx: Sharp, *Restrosternal, Improved with sitting up and leaning forward, Friction Rub* Common presentations: young, chest pain, no risk factors, after viral infection Dressler's common after procedure for MI

What is Pericarditis?

Inflammation of the pericardium which is usually idiopathic or viral (90%). Other causes include bacterial, autoimmune, connective tissue disease, neoplasm, radiation, chemo, drug toxicity, cardiac surgery, or myxedema. MC in men and <50 yo.

What is cervicitis?

Inflammed, friable cervix that is quick to bleed

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.

Pt presents with anesthesia of the maxillary division (V2) of the trigeminal nerve, what are you thinking?

Infraorbital nerve entrapment

Brown recluse spider bite

Initial bite is painless Vemon is necrotizing - reactions range from mild urticaria to full thickness necrosis. Lesion is a sinking macule, pale gray in color, slightly eroded in center, with halo of tender inflammation and hemorrhage Lesion extends to muscle

Goal of tx with hypertensive emergency

Initial goal is to reduce MAP by no more than 25% within minutes to 1 hour with further lowering over next 2-6 hours

Coup injury

Injury directly below the point of impact

Symptoms of PVD?

Intermittent claudication Rest pain ED Sensorimotor impairment Tissue loss

Aortic Dissection

Intimal tear with leaking blood into media and longitudinal cleavage from the adventitia Risk factors: *HTN*, connective tissue disease (Marfan's), pregnancy, smoking, aortic valve abnormalities M>F, 50-70 years old, 33% mortality if untreated

What is Asherman syndrome?

Intrauterine adhesions usually due to trauma (usually from D&C)

____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

Ellis I fracture

Involves enamel only - No acute intervention is necessary

Ellis III fracture

Involves the enamel, dentin and the pulp - Urgent dental follow-up - Rx ABX and oral analgesia

AFib

Irregularly Irregular Rate Control Rhythm Conversion Cardioversion if unstable

What are two types of contact dermatitis?

Irritant - caused by a chemical (ex: detergents) Allergic - caused by an allergen (ex: poison ivy)

What is the number one question you want to ask if a patient present with vaginal bleeding?

Is she pregnant? - Pregnancy-related complications are the most common cause of abnormal vaginal bleeding in women of reproductive age

CVA Signs and Symptoms

Ischemic: Abrupt, loss of function, Multiple syndromes based on anatomy, HTN Hemorrhagic: Abrupt, Loss of Function, Vomiting, Headache, Altered mental status (coma), HTN (>200 systolic often)

CVA Treatment

Ischemic: Activate stroke team, TPA vs Intervention, Modest BP control (no more than 25% decrease) <185/110 Hemorrhagic: Activate Stroke Team, Contact neurosurgeon, Modest BP control (variable practice, Nimodipine), Consider FFP, rVIIA, platelets, Reverse anti-coagulation

What causes central vertigo?

Issue with balance centers of the brain

Presentation of Mandibular fracture

Jaw pain, malocclusion, numbness of the lower lips, and often obvious deformity

acute rheumatic fever Sx (diagnostic criteria)

Jones Criteria (diagnosis) Major: polyarthritis carditis subcutaneous nodules erythema marginatum syndeham chorea Minor: fever arthralgia elevated acute phase reactants (ESR, CRP) EKG showing heart block (prolonged PR interval)

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

How do you treat 1st degree burn?

Keep clean +/-neosporin Analgesics Hydration

What would you find on a CXR with CHF?

Kerley B lines Pulmonary edema Cardiomegaly Pulmonary effusions Venous dilations

____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

which type of breathing is associated w/ DKA... Kussmaul respirations, or Cheyne Stokes?

Kussmaul. this occurs w/ any metabolic acidosis. these are deep and regular breaths.

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 would you find on an EKG with CHF?

LA hypertrophy Arrhythmias (can be any rhythm) LV Hypertrophy

What EKG finding is highly suspicious for STEMI?

LBBB

Where is mitral stenosis best heard?

LLD position at APEX with full exhalation. No radiation.

Acronym for tx of CHF exacerbation

LMNOP Lasiks (furosemide) Morphine (vasodilator) Nitrates (vasodilator) Oxygen Position

What is an exudative pleural effusion caused by?

LOCAL ↑capillary and membrane permeability, usually infectious

Describe the pathophysiology of left sided heart failure

LV can't pump blood so fluid backs up in to the lungs and causes pulmonary symptoms

S4 gallop is pathologic and can indicate what? (3)

LV diastolic dysfunction LV hypertrophy Acute MI

____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 surgical tx of EP?

Laparoscopy is standard Laparotomy if patient is unstable or has known adhesions

What are clinical features of Bullous Pemphigoid?

Large TENSE bullae Negative Nikolsky sign Bleeding erosions may occur Axillae, thigh, groin, and abdomen are commonly affected. Mucous membrane lesions are less severe and painful than Pemphigus Vulgaris.

Arrhythmia Considerations

Large and heterogeneous group of conditions in which there is abnormal electrical activity in the heart. Benign vs. Malignant, Asymptomatic vs. Symptomatic (palpitations, dizziness, weakness, chest pain, dyspnea) Fast or slow, Stable or unstable Multifactorial

What is the pathophysiology of burns?

Leads to direct injury of skin and then inflammatory response Loss of barrier leads to fluids out and bacteria in There can be pulmonary damage which leads to inhalation of CO and other particulate matter

What side diaphragm injury is most common?

Left (Sits up higher)

Disease of which coronary artery results in the highest rate of mortality?

Left main coronary artery (LAD+circumflex)

What are indications for CABG?

Left main disease 2+ vessel disease Unstable angina refractory to medical management/PTCA Postinfarct angina Coronary artery rupture, dissection, or thrombosis after PTCA

Kehr sign

Left shoulder pain caused by blood in the peritoneal cavity.

What is a common cause of right side heart failure?

Left sided heart failure

Where is Cellulitis most commonly found?

Legs Face Trunk Arm

How do you treat TEN?

Like a burn victim - admit to burn unit Emergent derm consult

Most common type of skull fracture?

Linear skull fractures

Most commonly injured organ?

Liver

Shock Treatment

Look for underlying cause All bleeding stops....Eventually IV access (Central) -2 Large bore IVs Fluids first then blood Antibiotics early, source control Pressors after fluids and blood Ionotrops Epinephrine Consider Steroids (Stress dose steroids)

What is burn shock?

Loss of fluid from the intravascular space as a result of burn injury which causes "leaking capillaries" that require crystalloid infusion

What is chronic venous insufficiency?

Loss of wall tension of veins which causes stasis. Associated with history of DVT, leg injury, or varicose veins.

How does MR sound? Where is it heard and where does it radiate to?

Loud, BLOWING, high-pitched, PANSYSTOLIC at apex radiating to axilla

What would you find in an Echo with CHF?

Low EF (if systolic dysfunction) Hypertrophy Valve abnormality Wall abnormalities

Clinical features of PID?

Lower abdominal and pelvic pain which is bilateral Nausea HA Lower back pain +/- Fever Chandelier sign Purulent discharge

Where does a DVT most commonly occur?

Lower extremities (Long saphenous vein)/pelvis

_____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

Appendicitis

Luminal obstruction-mucous accumulation-increased pressure-lymphatic obstruction- perforation Most common in 2nd and 3rd decades Classic: *Periumbilical pain, dull, migration to RLQ, sharp*, anorexia, vomiting, fever

EKG is ordered for patients suspected of having Lyme disease... why?

Lyme dz can cause carditis, namely a third degree heart block

Who is most affected by pilonidal disease?

M>F Ages 15-30

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

MCL - medial collateral ligament

Management of ACS?

MONA + Plavix IVF Strict bed rest with telemetry Serial EKGs Pulse ox PCI for STEMI

What are the pre hospital treatments for ACS?

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

Modality of choice for suspected spinal cord lesions?

MRI

How are SCIWORA pts evaluated?

MRI and neurosurgical evaluation

Which is one of the most sensitive tests to quantify the extent of an infarction?

MRI with gadolinium

What imaging studies can be done for amenorrhea?

MRI/CT of hypothalamus and pituitary or pelvis Pelvic US or TVUS

Number one cause of trauma associated deaths?

MVAs

Torsades medical tx

Mag (I think this is sufficient to get them back into bradycardia) followed by a beta agonist such as isoproterenol, or in my experience atropine (if i recall correctly)

What can be used for refractory cases of asthma exac?

Mag Sulfate

How do we treat Torsades de pointes?

Magnesium

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

Risk factors for acute MI?

Male Increasing age Smoking HTN HLD Diabetes Family Hx Menopause Cocaine use

Cysts in postmenopausal women are ______ until proven otherwise

Malignant

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

Malignant

Second most common facial fracture?

Mandibular Fx

Tx of Tooth subluxation

Manipulate into proper position and splint where indicated

____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

Most common bone fractured in an orbital wall fx?

Maxillary bone

What is Long QT syndrome?

May be congenital or acquired. Associated with recurrent syncope, QT interval that is .5-.7 seconds long, ventricular arrhythmias, and sudden death

Clinical features of pericardial effusion?

May be painful or painless. Cough and dyspnea are common.

Counseling for breast feeding with mastitis?

May continue because the source is likely from the infant Breast feeding may continue on unaffected breast Use of a breast pump may reduce congestion of the infected breast

What are the 6 childhood exanthems (rash-causing diseases)?

Measles (Rubeola) Scarlet fever German measles (Rubella) Filatov-Dukes disease Fifth disease (Erythema Infectiosum) Roseola

What is CK-MB useful for?

Measure when reevaluating for reinfarction because Troponin remains elevated for 5-7 days

Clinical features of Gonorrhea?

Men - burning on urination, milky discharge which progresses to yellow, creamy discharge and urethral pain is more pronounced Women - Asymptomatic, dysuria, frequency, urgency, purulent urethral discharge. Vaginitis and cervicitis are common.

Medical tx of EP?

Methotrexate treats 80% of EPs

Typical tx for EP?

Methotrexate vs surgical (laparoscopy)

What is 1st line therapy for Trich?

Metronidazole 2g PO x1

How do you treat BV?

Metronidazole 500mg PO BID for 7 days or gel (5 days) Clindamycin cream x 7 days

What is the pregnancy rate with mild endometriosis? Moderate? Severe?

Mild - 75% Moderate 50-60% Severe - 30-40%

What are clinical features of Erythema Infectiosum?

Mild flu like illness Rash at 10-17 days (not contagious with rash) SLAPPED CHEEKS LACEY arms and legs Arthralgias in older patient Can cause fetal death in 1st trimester

Exanthematous Drug Reactions

Mimics measles like viral exanthem-symmetric brightly erythematous macules and papules, discrete and confluent Systemic involvement is low "Morbilliform or maculopapular drug reaction MC type of drug reaction!!

Renal Lithiasis

Mineral precipitation in collection system, Abrupt & sharp, Flank to groin pain, Writhing pain, N/V, diaphoresis DDx: Cholecystitis, splenic rupture, appendicitis, torsed gonad, shingles, trauma, diverticulitis, pyelonephritis IV, fluids, pain control (ketorolac) UA: expect hematuria, causion pyuria Non-contrast CT vs US +/- CBC, BMP Urology follow up, Tamsulosin, Opiate, Strainer

Scabies

Mite Sarcoptes scabiei Burrow into skin and deposit eggs which mature in 10-14 days Highly contagious because infested humans do not manifest sign or sx for 3-4 weeks SEVERE ITCH, worse at night

is a holosystolic murmur is heard, think of what 3 conditions

Mitral regurg. Tricuspic regurg. Ventricular Septal Defect

______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

What valve is affected with Rheumatic heart disease?

Mitral valve - causes stenosis

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

Mitral valve prolapse

Which heart blocks require pacing?

Mobitz Type II 3rd degree

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

What are types of ovarian cysts?

Most are functional (90%): Follicular, Corpus luteum (Luteal cyst), theca lutein cysts Malignant

What is Bullous Pemphigoid?

Most common bullous autoimmune disease! Autoantibodies, complement fixation, neutrophils, and eosinophils cause bullous formation

Uncal Transtentorial herniation

Most common herniation - Usually caused by an expanding lesion in the temporal lobe or lateral middle fossa -May cause fixed and dilated ipsilateral pupil, with progression will cause contralateral motor paralysis

What is anaphylaxis?

Multiorgan system involvement that occurs within seconds to hours after exposure to a known allergen that may lead to CV collapse

Clinical features of A. fib?

Multiple, small areas of the atrial myocardium are continuously discharging in a disorganized fashion. Irregularly irregular without p waves

What are causes of junctional rhythms?

Myocarditis CAD Dig toxicity Hyperkalemia

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

Myoglobin

What are the cardiac biomarkers for diagnosis of MI? Which is the most specific? Which is the most sensitive?

Myoglobin <---most sensitive Troponin I Troponin T <----most specific CK-MB

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

What are expectant management treatments for endometriosis?

NSAIDs Prostaglandin synthetase inhibitors COCs Progestins (Depo-Provera, IUD) Narcotics - try to avoid Danazol GnRH agonist

What is first line therapy for treatment of dysmenorrhea? What is the MOA?

NSAIDs - they inhibit prostaglandin synthesis and decrease the volume of menstrual flow.

How do you treat primary dysmenorrhea?

NSAIDs before menses and continue for 2-3 days OCPs Vit B Magnesium Acupuncture Heat Regular exercise

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

Naloxone; Flumazenil; Sodium Bicarbonate

Most frequently fractured bone in the face?

Nasal bone

What causes Gonorrhea?

Neisseria gonorrhoeae - a Gram neg intracellular diplococcus transmitted by sexual activity. MC in 15-29 year olds. Incubation is 2-8 days after exposure.

What are some compensatory mechanisms for CHF?

Neuro-hormonal system RAAS Ventricular hypertrophy

name the two most common etiological agents of bacterial meningitis occurring in college students

Niesseria meningitides, Streptococcus pneumonia

Diagnostic studies for PROM?

Nitrazine paper Fern test Amnisure US - checks amniotic fluid index

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

What medications are recommended for BP control in aortic dissection?

Nitroprusside and a B-blocker

Can you diagnose CHF by itself?

No - always an underlying pathology

What are PE findings with hypothalamic-pituitary insufficiency? Labs? Tx?

No breast development Labs: Low FSH and LH Tx: Cyclic estrogen and progesterone

What are clinical features of endocarditis?

Non-specific symptoms (fever, cough, dyspnea, arthralgias, GI complaints, pallor) Splenomegaly Murmur that may change PATHOGNOMONIC findings (occur in 25% of pts): Palatal, conjunctival, or subungual petechia Splinter hemorrhages Osler nodes (painful, violaceous, raised lesions of the fingers, toes, feet) Janeway lesions (painless red lesions or palms or soles) Roth spots (exudative lesions of the retina)

Clinical features of ACS?

Nontraumatic severe chest pain which is prolonged >30min even at rest Crushing retrosternal pain Heaviness/tightness Unexplained indigestion Epigastric pain Diaphoresis, dyspnea, nausea, vomiting, weakness, anxiety, restlessness, light-headedness, syncope

What is contractility?

Normal ability of muscle to contract at a given force for a given stretch. It is independent of preload/afterload

What are PE findings for an imperforate hymen?

Normal breast developement Labs: none Tx: Surgically open

What are PE findings for Androgen insensitivity? Labs? Tx?

Normal breast development Labs: High testosterone Tx: Remove testes, start estrogen

What is sinus tachycardia?

Normal sinus P waves and PR interval with atrial rate between 100-160.

Who is most commonly affected by endometriosis?

Nulliparous women in their 20s and early 30s

ED tx for anaphylaxis?

O2, prepare to intubate if necessary Limit exposure to allergen Epinephrine - first line med IVF with NS Steroids H1+H2 antihistamines (Benedryl + Zantac) B2 agonists or duo-neb

What is Peripheral arterial disease (PAD)?

Obstruction of arteries NOT within the carotids, brain, or aortic arch. Commonly caused by atherosclerosis.

Pulmonary Embolism

Occlusion of pulmonary artery Most originate from thrombi in pelvis/LE >400K per year Current or previous , Malignancy, obesity, estrogen, immobility, trauma, surgery are risk factors S/Sx: Dyspnea, pleuritic chest pain, hemoptysis (late), tachypnea, tachycardia

What is the MC site of arterial atherosclerotic occlusion in the lower extremities?

Occlusion of the superficial femoral artery (SFA) in Hunter's canal

What is the most common cause of an EP?

Occlusion of the tubes due to adhesions

What are some causes of tachycardia?

Occurs in response to one of three categories of stimuli: 1. Physiologic (pain, exertion, stress) 2. Pharm (sympathomimetics, caffeine, bronchodilators) 3. Pathologic (fever, dehydration, hypoxia, anemia, hyperthyroidism, PE, heart failure)

Incomplete spinal cord lesion

Occurs when motor, sensory, or both functions are present below the level of the lesion

What is orthostatic hypotension?

Occurs when there is a sudden change in posture after being supine for a prolonged period and is associated with inadequate compensatory increases in heart rate and peripheral vascular resistance

What are causes of vasovagal syncope?

Occurs when your body overreacts to certain triggers, such as the sight of blood or extreme emotional distress. Vasodilation and reflex bradycardia occur.

Burst Fracture

Occurs with AXIAL LOADING and causes the vertebral body of C3-C7 to shatter outward from the compressive force - Disrupts the anterior longitudinal ligament

What will you find on PE with endometriosis?

Often normal pelvic exam May have tender nodularity of the cul-de-sac and uterine ligaments and a fixed, retroverted uterus Adenexal masses

How does mitral stenosis sound?

Opening SNAP Low-pitched mid-diastolic rumble (because blood is trying to get in to LV)

_______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

Golden hour

Optimum limit of time between the moment of injury and definitive care at a hospital

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

Orchiitis

What are lice?

Organism - Pediculosis humanus and Pthirius pubis-1-3mm long flattened lice with 2 pairs of legs and claws

Clinical features of A. flutter?

Originates from small area within the atria. Regular atrial rate between 250-350 Saw tooth waves

What are complications from ulcers?

Osteomyelitis Bacteremia Sepsis

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

What are the most common ovarian growths?

Ovarian cysts

What should be in your Ddx for acute pelvic pain?

Ovarian torsion or rupture of ovarian or fallopian tube cyst Functional ovarian cyst Endometritis/PID Ectopic pregnancy Appendicitis Acute cystitis Ureteral stone formation

______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

Where is endometriosis usually found? What is the most common site?

Ovaries (60%) Uterine cul-de-sac Uterosacral ligaments Posterior surfaces of uterus Pelvic peritoneum Look at bladder, bowel, appendix, ureter

What are features of a PAC on EKG?

P wave appears sooner than next expected sinus beat P wave has a different shape P wave may or may not be conducted through the AV node

35yo male presented to the ED w/ a fluctuant mass diagnosed as an abscess...

PA inquired about status of tetanus as the abscess has to originate somewhere... whether or not an abscess can start w/ a wound I do not know, but it does serve as a good reminder to inquire about tetanus status in a patient with a wound

Premature beats

PACs PJCs PVCs

What are clinical features of abruptio placentae?

PAINFUL vaginal BLEEDING Uterine, abdominal, or back pain Uterus becomes hypertonic, tender Fetal distress depending on separation

Hallmark of placenta previa?

PAINLESS vaginal bleeding is hallmark

How do you treat Scarlet fever?

PCN VK or Amoxicillin

What are other causes of DUB?

PCOS Exogenous obesity Adrenal hyperplasia

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

How do you treat scabies?

PERMETHRIN applied from chin to bottom of feet and left overnight (8 hours) then washed off in morning. Repeat tx in 7 days.

What should be on your Ddx with endometriosis?

PID Ovarian neoplasms Uterine myomas Ectopic pregnancy Adhesions

Ventricular arrhythmias

PVCs V tach Toursades Long QT syndrome Brugada syndrome V fib

What is the site of a arterial insufficiency ulcer vs. a venous stasis ulcer?

PVD arterial insufficiency ulcer is usually on toes/feet Venous stasis ulcer is usually over medial malleolus

What is rest pain?

Pain in the foot, usually over the distal metatarsals. This pain arises at rest, classically at night

Clinical features of dysmenorrhea?

Painful cramping in pelvic area/lower abdomen beginning before or at the onset of menses and lasting for 1-3 days PE, labs, imaging is normal for primary dysmenorrhea N/V/D Fatigue

Clinical findings of Zoster?

Painful eruption in a dermatomal pattern - often at T10. Trigeminal eruptions can include the tip of the nose (Hutchinson sign) - can risk corneal involvement

How does erysipelas present?

Painful localized redness, heat, and swelling. Raised, WELL-DEMARCATED, indurated border Often affects face and legs NO SITE OF SOURCE or port of entry, unlike cellulitis

What is secondary dysmenorrhea?

Painful menstruation caused by an identifiable clinical condition, usually in the uterus or pelvis. Usually affects women >25 yo

What is primary dysmenorrhea?

Painful menstruation caused by excess prostaglandin and leukotriene levels. Onset is usually within 2 years of menarche. There is NO pathologic abnormality.

What will PE reveal with pilonidal disease?

Painful, fluctuant area the sacrococcygeal cleft Tuft of hair emerging from the midline opening in the natal cleft

Diagnostic procedures/imaging for DUB?

Pap Endometrial biopsy Pelvic US Hysterosalpingography Hysteroscopy D&C

____is optic disc swelling caused by increased intracranial pressure.

Papilledema

What are cardiac PE findings with CHF?

Parasternal lift Enlarged or displaced PMI Diminished first heart sound S3 gallop S4 gallop in diastolic failure

What is thrombophebitis/DVT?

Partial or complete occlusion of a vein plus inflammatory changes

Who is most affected by EM?

Patients 20-40 yo Males>Females

Who does Bullous Pemphigoid usually present?

Patients >60

WHen would mechanical ventilation be required for asthma exac?

Peak flow <25%

Diagnostic studies for ovarian cysts?

Pelvic US - will be mobile, fluid filled, and simple Abdominal and Pelvic CT

____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)

When is renal imaging indicated?

Penetrating trauma Pediatric trauma Deceleration injury Adult blunt trauma

How do you treat mastitis?

Penicillinase-resistant antibiotic (Cloxacillin, dicloxacillin, nafcillin) Cephalosporin Hot compresses Keep breastfeeding/pumping

What is the surgical option of treating AS in patients who are poor surgical candidates?

Percutaneous balloon aortic "valvuloplasty"

How are recurrent pericardial effusions treated?

Pericardial window

What is Dressler's syndrome (post MI syndrome?)

Pericarditis, fever, leukocytosis, pericardial or pleural effusions

Cullen sign

Periumbilical discoloration indicative of peritoneal bleeding

Tx of lice?

Permethrin on body Pyrethrin with piperonyl butoxide in hair Fine-tooth comb to remove dead lice and nits Wash all clothing, bedding, etc

What is Sick Sinus Syndrome?

Physiologically inappropriate sinus bradycardia, sinus pause, sinus arrest, or episodes of alternating sinus tachycardia and sinus brady. Occurs most often in elderly due to scarring of the heart's conduction system or infants who have had heart surgery

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

Pleural effusion.

Most common complication of Pulmonary contusion and hematoma?

Pneumonia

when evaluating any chest pain pt, you need to rule out the big red flag conditions. mnemonic for them is PACE PM... name each of these letters

Pneumothorax Aortic aneurysm Cardiac tamponade Esoapheal rupture Pulmonary embolism Myocardial infarction

What is torsades de pointes?

Polymorphic V tach in which the QRS complex twists around the baseline. May occur spontaneously or when the patient has hypokalemia or hypomagnesemia or following meds that prolong the QT

____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 the most common cause of secondary amenorrhea?

Pregnancy

What 3 factors does cardiac output depend on?

Preload Contractility Afterload

What is Abruptio placentae?

Premature separation of a normally implanted placenta after the 20th week but before birth

How do you treat decubitus ulcers?

Prevention! Repositioning Massaging prone areas Frequent monitoring Minimize friction Moist sterile gauze if ulcer develops Surgical debridement

What are risk factors for an EP?

Previous EP Hx of PID Previous abdominal or tubal surgery IUD use Assisted reproduction

How does primary and secondary dysmenorrhea change with age?

Primary - decreases with age Secondary - increases with age

ergonovine challenge is used for what condition?

Prinzmetal angina

35yo female presents w/ CP that started this morning and has been constant ever since; otherwise asymptomatic. Troponin negative but EKG shows ST elevation... diagnose

Prinzmetal angina... she's relatively young (tends to occur in those under 50), more common in females, tends to start in the morning, may cause ST elevation but have negative troponins

Elements of history to obtain in a patient with ACS symptoms?

Prior CABG, PCI? CAD, angina, previous MI? Risk factors? Family hx? PMHx? Substance use? Previous cardiac tests (EKG, Echo, Stress test, Cath)?

What is the hallmark of vasovagal syncope?

Prodrome of dizziness, nausea, pallor, diaphoresis, and diminished vision while standing

What is a corpus luteal cyst?

Produced each cycle following ovulation from the remanants of the follicular cyst. It produces progesterone to maintain a pregnancy. If the patient does not get pregnant, progesterone levels decrease and withdrawal bleeding occurs. It is NORMAL in pregnancy but can cause pain.

What is Toxic Epidermal Necrolysis (TEN)?

Progression of SJS to full thickness skin detachment. >30% skin loss

Clinical features of chronic venous insufficiency?

Progressive edema followed by skin changes Itching, dull pain with standing, ulceration Shiny, thin skin with pigment and sub-Q changes Stasis ulcer just above the ankle

What are signs/symptoms of Vulvovaginal candidiasis (VVC)?

Pruritis Vaginal soreness Dysparunia External dysuria Vaginal discharge - resembles cottage cheese, no odor

Subacute subdural hematoma

Pts may not have symptoms for days after the injury - CT scan shows ISODENSE lesions

A Fx of the 1st and 2nd rib are associated with?

Pulmonary, Cardiac, Vascular injury

____is an early systolic opening ejection click followed by a systolic ejection murmur which radiates to the base.

Pulmonic Stenosis

How do you diagnose Bullous Pemphigoid?

Punch biopsy half blister/half normal skin. Send one to pathology and the other for immunofluorescence. You will see linear IgG deposits along basement membrane.

____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

give the proper definition of each: QRS (on an EKG)

Q is the first downward deflection which precedes an R which is the first upward deflection (if there are two upward deflections, the smaller is called an r or r') and S is the first downward deflection after the R wave

what is a more common EKG change that occurs in kids (considered to be abnormal, but a more common abnormality)

QTc prolongation

What is the path of blood through the heart?

RA, Tricuspid, RV, Pulmonic valve, Pulmonary artery, Lungs, Pulmonary veins, LA, Bicuspid (Mitral) Valve, LV, Aortic valve, Aorta

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

Describe the pathophysiology of right sided heart failure

RV can't pump so there is a back up of blood from the periphery

Clinical features of arrhythmias?

Ranges from: Asymptomatic Hemodynamic instability Shock Death

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 are clinical features of German Measles?

Rash that starts on the face and spreads to the rest of the body (less intense than measles) Low grade fever Postauricular and occipital adenopathy Aching joints, especially among young women. FORCHEIMER spots (fleeting small, red spots on the soft palate) - can also be seen with measles and scarlet fever.

What is shingles?

Reactivation of the varcella virus that has been dormant in ganglionic satellite cells.

What are risk factors for VVC?

Recent antibiotic use Pregnancy Diabetes Tight, non-breathable clothing Chronic steroid use

What is the "classical" appearance of endometriosis?

Red spots Dark blue Dark black Dark brown "Powder burn" Cystic

What are characteristics of first degree burn?

Red, blanches, painful No blister Minimal tissue destruction Most common cause: Sunburn Heals in 7-10 days No scarring

How does Cellulitis present?

Red, hot, edematous, shiny, tender plaque with irregular borders. Center may be nodular and there may be purulent discharge.

What are characteristics of second degree superficial burns?

Red, painful Wet with blisters Most common cause: Scalding Heals 14-21 days May or may not have scarring

What are different kinds of SVT?

Reentrant SVT - present with PSVT Ectopic SVT

What is preterm labor?

Regular uterine contractions (>4 in 6 hours) between 20-36 weeks of gestation and presence of one or more of the following signs: 1. Cervical dilation of 2cm+ on presentation 2. Cervical dilation of 1cm+ on serial exams 3. Cervical effacement of greater than 80%

What is supraventricular tachycardia (SVT)?

Regular, rapid rhythm that arises from impulse reentry or ectopic pacemaker above the bifurcation of the bundle of His. BPM is >160

Tx for 2nd degree burns?

Remove blisters Apply Silvadene and dressing Analgesics

How do you treat contact dermatitis?

Remove offending agent Wet dressings soaked with Burrow's solution (aluminum acetate in water) Topical corticosteroids (Class I or II) Do not pop blisters If severe: systemic corticosteroids with a 2 week taper starting at 60mg Supportive care: mild soaps, oatmeal baths, antihistamines

If EKG is negative for STEMI but patient is symptomatic what is the next step?

Repeat EKG Get cardiac biomarkers

Tx for AA?

Replace with graft, either endovascular or open surgical repair (5 year survival is >60%)

What are important elements of the history you should ask for a patient presenting with vaginal bleeding?

Reproductive history - menarche, LMP, dysmenorrhea Sexual history - contraception, sexual partners, h/o STIs History of trauma? Retained FB? Meds PMHx - coagulopathies, PCOS, thyroid disease Associated symptoms - GI, urinary, musculoskeletal

What are pressure ulcers (decubitus)?

Result from impaired blood supply caused by localized pressure. Sacrum and hip are most commonly affected.

Primary Spinal cord injury

Result of mechanical disruption, transection or distraction of neural elements

Secondary Spinal cord injury

Result of vascular, chemical, and inflammatory process that follows primary injury

Diagnostic procedure of choice for bladder injuries?

Retrograde Cystogram

Procedure of choice to diagnose all suspected urethral injuries?

Retrograde Urethrogram (RUG)

Most common injury from blunt thoracic trauma?

Rib Fracture

Treatment of PAD?

Risk factor modification (smoking cessation, diet modification, exercise, etc) BB ACE-I Statins ASA or Plavix Cilstazol (Pletal) Revascularization

What are clinical features of cord prolapse?

Ropelike, soft, elongated mass on speculum exam or bimanual. This is an OB emergency!

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

What is Premature rupture of membranes (PROM)?

Rupture of amniotic membranes before the onset of labor at or beyond 37 weeks of gestation. Occurs in 8% of pregnancies. 90% of women will go in to labor within 24 hours of PROM. Preterm PROM occurs before 37 weeks.

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

PE EKG

S in lead 1, Q in lead 3, and inverted T in lead 3 are characteristic findings

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

on which anatomical structure of the heart do epinephrine and norephinephrine work

SA node

pathophysiology of sick sinus syndrome

SA node has completely random firing resulting in periods of tachycardia and periods of bradycardia

What is sinus bradycardia?

SA node rate is <60 BPM usually in response to one of three categories of stimuli: 1. Physiologic (vagal tone) 2. Pharm (CCBs, BBs, Dig) 3. Pathologic (AMI, increased ICP, carotid sinus hypersensitivity, hypothyroidism, sick sinus syndrome)

What defines orthostatic hypotension?

SBP drop of >20 and DBP drop of >10 Rise in pulse of >15

defintion of severe HTN

SBP of at least 180 or a diastolic of at least 110

which class of antidepressant is venlafaxine

SNRI

What are general signs and symptoms of CHF?

SOB and fatigue Orthopnea Edema Nocturia Hypotension/narrow pulse pressure Diaphoresis Pulmonary congestion JVD Tachycardia and tachypnea

Orthopnea

SOB when lying down, relieved by sitting up and sleeping with pillows

target blood pressure for transfusion in a hemorrhagic patient

SPB>90

EKG changes with an NSTEMI?

ST segment depression Q-wave

What is Chlamydia?

STD caused by a large group of obligate intracellular parasites. MC cause of nongonococcal urethritis. Leading cause of infertility

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

Clinical features of aortic rupture?

Same as dissection + hypotension/shock

What is referral criteria for transfer to a burn center?

Second degree with >15% of BSA (or >10% for high risk patients) Third degree with >5% BSA Concomitant trauma Comorbid conditions Burns on face, hands, feet, genitals, or major joints Circumferential chest or extremity burn Electrical, chemical, inhalation burn Severe drug reaction (treated just like burns)

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

Status Epilepticus

Seizure lasting more than 30 minutes or repetitive symptoms without lucid interval Tx: Benzo's (ativan), Fosphenytoin (faster than phenytoin), Barbiturate vs Propofol (intubated), Consider Toxin/Eclampsia if still refractory, Neuro ICU with EEG

How do you treat EM?

Self-limiting disease Supportive care: Antihistamines, topical steroids, prednisone Control Herpes outbreaks with Acyclovir

What is aortic dissection?

Separation of the walls of the thoracic aorta from an intimal tear and disease of the tunica media. A false lumen is created and a "reentry" tear may occur, resulting in a double barrel aorta

Death in the third peak is typically due to?

Sepsis or multiple organ dysfunction

____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 are diagnostic studies for a spontaneous abortion?

Serial hCG titers, serum progesterone, or serial U/S to confirm a viable pregnancy

What are diagnostic studies for an EP?

Serum hCG - will be low for GA (normally doubles q48 hrs) TVUS - IUP should be seen when hCG levels are between 1500-2000

What are follow up requirements for tx of EP?

Serum hCG levels should be done or pelvic exam to exclude any remaining evidence of pregnancy

What is the criteria for treatment of an EP with MTX?

Serum hCG titer of <5000 Ectopic mass of <3.5cm on ultrasound No hx of blood disorders, PUD, or pulmonary disease Thrombocytes >100,000 Normal renal and hepatic function Hemodynamically stable pt Reliable pt who will follow up

Hypertensive urgency

Severe HTN (>180/110) without signs of end organ damage

Hypertensive emergency

Severe HTN with end-organ damage

What are clinical features of a ruptured EP?

Severe abdominal/shoulder pain due to peritonitis Tachycardia Syncope Orthostatic hypotension

What are the s/s of labyrinthitis and vestibular neuritis?

Severe, disabling vertigo for 24-48 hours followed by weeks of imbalance -Vomiting -Pts think they are dying

What are risk factors for PID?

Sex Age 15-25 STI in partner Previous PID Not using condoms

What are PE findings with Turner syndrome? Labs? Tx?

Short webbed neck No breast development Labs: high FSH Tx: Cyclic estrogen and progesterone

What kind of murmurs are usually benign?

Short, soft, systolic murmurs that are asymptomatic often don't require further investigation

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

What are the current recommendations for screening for AA?

Single abdominal US in men >65 who have ever smoked followed by contrast CT

Supraventricular Rhythms

Sinus Arrhythmia Sinus Brady Sinus Tachy PACs PSVT SVT due to accessory pathways A fib A flutter Junctional rhythm PJC MAT

Atlanto-occipital dislocation

Skull displacement from atlas, either anteriorly, superiorly, or posteriorly; vertebral artery may be damaged and dens of axis may be pushed against medulla oblongata (Internal decapitation)

____lesions have a depression in the center, spread from the face/arms to trunk/legs, and are all at the same stage.

Small pox

What women with what conditions should not be given OCPs?

Smokers HTN DM Vascular disease Breast Cx Liver disease Focal headaches

What are risk factors for spontaneous abortion?

Smoking Infection Systemic disease Immunologic parameters Drug use

What are some common chemicals that cause irritant CD?

Soaps, cleaners, solvents, detergents

Whiplash

Soft tissues surrounding the cervical spine get overly-stretched or damaged as a result of a whipping hyperflexion/extension action. Most often happens in car accidents & falls

ED rash cocktail

Solumedrol Benedryl Zantac

What is peripheral vascular disease (PVD)?

Spectrum of disease of peripheral vessels. Includes PAD, varicose veins, thrombophlebitis, DVT, and chronic venous insufficiency.

First priority in multiple trauma

Spinal Immobilization (Along with assessment of airway)

How is spinal shock distinguished from neurogenic shock?

Spinal shock causes loss of all neurologic function below the level of the lesion - Neurogenic shock is characterized by autonomic dysfunction

Second most commonly injured organ?

Spleen

A Kehr's sign is usually indicative of?

Splenic injury

What is key to treatment of arrhythmias?

Stable patients are treated with medicine Unstable patients (dyspnea, AMS, hypotension) are treated with electricity

_____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)

pneumonia is a potential complication of influenza (those w/ the flu may get pneumonia shortly after). what is the most common etiological agent in this case?

Staph aureus

What are the most common causative agent of Cellulitis?

Staph aureus Strep

What causes impetigo?

Staph aureus (50-70%) Strep

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)

What is Virchow's triad?

Stasis Injury Hypercoagulable state

Tx for pericarditis?

Steroids NSAIDs Antibiotics if bacterial Pericardiectomy if constrictive pericarditis

What is the tx for labyrinthitis and vestibular neuritis?

Steroids/PT

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

How do you treat SJS?

Stop offending drug Supportive care: Replace fluids and electrolytes, high caloric supplementation Cool Burrow solution (aluminum acetate) Prevent sepsis

How do you manage fetal distress?

Stop pitocin (if applicable) Change maternal position Administer O2 Measure fetal scalp pH

most common etiological agent of pneumonia

Strep pneumo

four etiological agents of pneumonia

Strep pneumo (most common), M. catt, H. influ, Staph aureus (typically following a viral infection)

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

What causes infective Endocarditis?

Strep viridans Staph aureus Enterococci

Endocarditis (or infection of the endothelial surface of the heart) is most commonly caused by what bacteria?

Strep viridans, Staph aureus, and Enterococcus

What are PACs associated with?

Stress Fatigue Alcohol/tobacco use Caffeine COPD Dig toxicity CAD

What is the best test when you have a stable patient with no EKG changes and no cardiac biomarker elevation?

Stress test

What is a rare complication of Measles?

Subacute sclerosing panencephalitis (SSP) - fatal encephalitis that occurs years after initial infection

____hematoma is an aneurysm presenting with a thunderclap headache, stiff neck, and delirium.

Subarachnoid

What type of hemorrhage is commonly spontaneous and atraumatic?

Subarachnoid hemorrhage

What is endometriosis associated with?

Subclinical peritoneal inflammation - with every period you get increased peritoneal fluid, increase of fluid white cells, and inflammatory cytokines

_____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

Most common type of Cardiac contusion?

Subendocardial

What is the primary pharmacotherapy for angina?

Sublingual nitroglycerine

What is classic anginal chest pain?

Substernal/epigastric anterior chest pain Dull, fullness, pressure, tightness, crushing, squeezing Radiates to arm, neck, back, jaw

Paralytic agent used in Rapid Sequence intubation?

Succinylcholine

What are the s/s of menieres disease?

Sudden unilateral SNHL, roaring tinnitus, and vertigo for hours -Ear fullness

What are some drugs that cause SJS?

Sulfonamides Penicillins Phenytoin Phenobarbital Carbamazepine Valproic acid Allopurinol Corticosteroids

Treatment for thrombophlebitis?

Superficial thrombophlebitis is treated with bed rest, local heat, elevation of extremity, NSAIDs Antibiotics Surgical intervention if serious

How do you treat Measles?

Supportive care - Measles is self-limiting (lasts 7-10 days)

How do you treat pilonidal disease?

Surgical drainage Follicle removal with unroofing of sinus tracts

Risk factors for DVT?

Surgical procedures (notably hip replacement) Prolonged bed rest Lower extremity trauma Oral contraceptives/HRT Inherited states (Factor V Leiden, protein C, protein S, antithrombin deficiencies) Elderly Obesity Travel Multiparity IBD Lupus

Torsed Gonad Male

Swollen, Firm, high-riding testicle Tansverse ie *Loss of cremasteric reflex* Pain Control Urology consult before ultrasound Reduction

How do you treat Rubella?

Symptomatic treatment

Treatment for Erythema Infectiosum?

Symptomatic tx

What are clinical signs/symptoms of endometriosis?

Symptoms are related to menses: Dysmenorrhea Dyspareunia Infertility Dyschezia (difficulty passing bowel movement) Intermittent spotting Chronic pelvic pain

WHat are the s/s of central vertigo?

Symptoms with gradual onset but are constant -May have nausea or diaphoresis -Vertical nystagmus

Aortic Aneurysm Signs and Symptoms

Symptoms: *Syncope and chest pain*, Sudden onset of abdominal, back, or flank pain, hematuria, scrotal mass, femoral neuropathy Signs: *Pulsatile mass*, ecchymosis, abdominal bruits, tenderness, distal extremity ischemia

Aortic Dissection Signs and Symptoms

Symptoms: Abrupt onset, Chest or back pain, *Tearing or Ripping* which propagates, *Neuroo deficits* Signs: Asymmetric BP, shock vs HTN, New murmur, Tamponade, may mimic AMI and CVA

Tx for unstable patient with V. tach who has a pulse?

Synchronized cardioversion

What is the initial treatment for unstable tachycardia/PSVT?

Synchronized cardioversion

What is the key principle of treating an unstable arrhythmia in a patient with a pulse?

Synchronized cardioversion

Tx of A.fib with RVR in an unstable patient?

Synchronized cardioversion with 100-200J

Tx of A flutter with instability?

Synchronized cardioversion with 50J

How do you treat Erysipelas?

Systemic antibiotics: PCN, Erythromycin, Celphalosporins, Azithromycin

What are clinical features of right sided heart failure?

Systemic vascular congestion JVD Tender or nontender hepatic congestion Decreased appetite/nausea Pitting edema Hepatomegaly

Describe what is happening to valves in Systole vs Diastole?

Systole - Mitral, Tricuspid close (S1), Ventricles contract Aortic and pulmonic valves close (S2), Ventricles fill

What is the difference between systolic and diastolic HF?

Systolic HF is a pumping problem due to decreased contractility which = decreased EF. Diastolic HF is a filling problem due to the heart being stiff (Ex: LVH). 40% of patients have diastolic HF. EF is preserved.

which class of antidepressant is amitryptyline (Effexor)

TCAD

name four classes of drugs that are commonly overdosed on resulting in coma

TCAD, benzos, opiates, antiepilectics

T/F All tongue laceration need prophylactic ABX

TRUE

T/F Brown-Sequard lesions affect all three major neural tracts

TRUE

T/F CT scan is very sensitive and specific for liver lacerations

TRUE

T/F Cardiac enzymes have not predictive value in Dx Commotio Cordis

TRUE

T/F Eye lid lacerations involving the lid margin. the nasolacrimal system, and the tarsal plate or levator muscle MUST be repaired by opthalmology

TRUE

T/F For a partial tear of the urethra 1 attempt at a foley placement may be done

TRUE

T/F Gastrograffin should be used in an esophagogram instead of Barium if trauma is suspected

TRUE

T/F Hypotenison is associated with Increased morbidity and mortality in trauma pts

TRUE

T/F In a renal injury, the degree of hematuria is not indicative of severity of injury

TRUE

T/F In central cord syndrome there is greater motor weakness in the upper extremities than in the lower extremities

TRUE

T/F In the absence of other trauma, sexual assault must always be considered with injuries to the female genitalia

TRUE

T/F Kussmaul sign is seen in pts with Cardiac Tamponade

TRUE

T/F Lumbar puncture is indicated with increased suspicion for subarachnoid hemorrhage and early normal CT scan

TRUE

T/F MRI is often more sensitive to diffuse axonal injury

TRUE

T/F Most bladder ruptures are extaperitoneal

TRUE

T/F Most intraoral lesions will heal on their own within 2-3 days

TRUE

T/F Most penile fractures need operative repair usually for the hematomas

TRUE

T/F Nasal fracture is a clinical diagnosis

TRUE

T/F Nasogastric and nasotracheal tubes are contraindicated in Le Fort III fractures

TRUE

T/F Nasogastric and nasotracheal tubes are contraindicated in Le fort III fractures

TRUE

T/F Nasogastric tube placement is contraindicated in trauma pts with suspected basilar skull fracture

TRUE

T/F Penetrating trauma pts should get ABX

TRUE

T/F Post menopausal females are at a higher risk for sternal Fx

TRUE

T/F Pts with CSF leaks are at an increased risk for meningitis and must be started on broad spectrum ABX

TRUE

T/F Pulmonary Contusions and Hematomas increase Risk for ARDS

TRUE

T/F Pulsus Paradoxus is seen in severe cardiac tamponade

TRUE

T/F Shaken baby syndrome is a cause of diffuse axonal injury

TRUE

T/F Suspected spinal cord injuries require MRI

TRUE

T/F TBI can alter Cerebral perfusion pressure (CPP)

TRUE

T/F The trauma pt who presents with significant head trauma, unconscious, with focal neurological deficit, or spinal tenderness has a cervical spine injury until proven otherwise

TRUE

T/F Trauma pts generally need a CT of Head, chest, and abdomen because of significant mechanism of injury

TRUE

T/F Type and Screen should always be ordered in a trauma scenario

TRUE

T/F a vaginal exam is indicated in all females who have pelvic fractures

TRUE

T/F disruption of 2 of the cervical spine columns causes instability of the cervical spine and danger to the spinal cord

TRUE

T/F the GCS is often predictive of outcomes

TRUE

T/F you can pass a foley catheter in a female with a pelvic fx

TRUE

T/F Foreign bodies, such as knives or bullets, should be left in place

TRUE (May be providing local tamponade)

T/F Massive hemothorax requires immediate tx without delay for imaging

TRUE (Tube thoracostomy)

T/F Foreign bodies such as knives or bullets should be left in place

TRUE (may be providing local tamponade)

Clinical features of cardiac tamponade?

Tachycardia Tachypnea Narrow pulse pressure JVD Pulsus paradoxus (breathing in causes drop in BP)

What are additional diagnostic criteria for PID?

Temp >38.3 (101) Abnormal cervical or vaginal mucopurulent discharge Presence of many WBCs on wet prep Elevated ESR Elevated CRP Gonorrhea or chlamydia test +

What is abortion?

Termination, whether miscarriage or therapeutic, before 20 weeks of gestation. Spontaneous abortion is miscarriage. Occurs in 15-20% of clinically recognized pregnancies.

I had traditionally associated S1Q3T3 on an EKG as being pathonomonic for a PE, but this applies to a right heart strain in general. what's the relationship between a PE and right heart strain

The clot in the pulmonary vasculature cuases blood to back up on the right side of circulation thus causing right heart strain

Secondary survey

The patient is evaluated from head to toe & the indicated studies (eg, radiographs, laboratory tests, invasive diagnostic procedures) are obtained.

What is Placenta previa?

The placenta partially or completely covers the cervical os

What is concealed abruption?

There is blood retained between the detached placentae and the uterus

How do progestins treat endometriosis?

They inhibit endometrial tissue growth

How do OCPs treat dysmenorrhea?

They inhibit proliferation of endometrial tissue--->less prostaglandins

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

How do we define V.Tach?

Three or more PVCs in a row. Can be stable or unstable. Frequent complication of acute MI and dialated cardiomyopathy

What is the best scoring system for deciding when a patient with ACS should undergo aggressive tx?

Thrombolysis In Myocardial Infarction (TIMI) score

DVT

Thrombus embedded in one of the major deep veins of the lower legs,thighs, or pelvis. Unilateral pain, *edema*, tenderness. massive clots may cause ischemia (compression) or arterial spasm Prior DVT, Malignancy, age >40, obesity, estrogen, pregnancy, trauma, catheters, orthopedic surgery are all risk factors

How do you treat resistant primary dysmenorrhea?

Tocolytics CCBs Progestogens

bradycardia is concerning b/c it can decompensate into another arrhythmia... what is that arrhythmia?

Torsades

name one arrhythmia that QT prolongation can lead to (this is the reason that QT prolongation is worrisome)

Torsades

Toxicology

Toxin and Antidote Salicylates- Sodium Bicarbonate Acetaminophen- N-acetyl cystine Opiates- Narcan Carbon Monoxide- O2, Hyperbaric oxygen Organophosphates- Atropine, 2-PAM Beta Blockers- Glucagon TCA's- Sodium Bicarbonate

What is the initial treatment for a symptomatic bradyarrhythmia?

Transcutaneous cardiac pacing! Atropine or positive chronotropic (epinephrine, dopamine)

What is syncope?

Transient loss of consciousness accompanied by loss of postural tone, followed by complete resolution without intervention. 50% that present to the ED have no definite etiology.

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

What are risk factors for abruptio placentae?

Trauma <---#1 HTN Smoking Decreased folic acid Cocaine use Alcohol use (>14 drinks/week) Uterine anomalies High parity Previous abruption AMA

Aortic disruption

Traumatic aortic rupture caused by Rapid deceleration or shearing forces

How do you treat Bullous Pemphigoid?

Treat fluid and electolyte disturbances Oral steroids Dapsone Tetracycline

How is pericarditis managed?

Treat underlying cause -NSAIDs, may need steroids -Pericardiocentesis if tamponade or large effusion present

How do you treat secondary dysmenorrhea?

Treat underlying condition Remove IUD if indicated Symptomatic tx (NSAIDs, heat, etc) Hysteroscopy, D&C, Laparoscopy (can both diagnose and treat)

Tx of acquired long QT syndrome?

Treatment of electrolyte abnormalities Discontinuation of drugs that prolong the QT

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 causes Trichomoniasis?

Trichomonas - a flagellated protozoan

_____is blowing and musical best heard along left sternal border.

Tricuspid regurgitation

If a pt presents with a flattened cheek bone, what type of fracture are you thinking?

Tripod fracture

Cardiac Markers: _____is the test of choice and appears 2-6 hours after MI and stays elevated for 5-10 days.

Troponin

Torsed Gonad

Twisting of ovary, testicle, or fallopian tube around is vascular pedicle Hx of enlarged ovary, recent physical activity, Sudden, severe, unilateral pain, *irreversible ischemia after about 6 hours*

How do you treat a black widow spider bite?

Tx: Antivenin (rarely indicated and not readily available) Diazepam Calcium gluconate

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

How does acute MI pain differ from angina pain?

Typically it is more severe and there are associated symptoms (SOB, diaphoresis, N/V, etc)

What studies are helpful for diagnosing endometriosis? What is the gold standard?

U/S MRI Laparoscopy with excisional biopsy and confirmatory histology - gold standard

How is NSTEMI/UA managed different from STEMI?

UA/NSTEMI you calculate a TIMI score to determine how aggressive to treat. Conservative management (ASA, Plavix, anticoagulation) is appropriate in low risk patients

alcoholic presents to ED w/ abdominal pain. after HPI and PE you're suspicious of cirrhosis. What's the go-to imaging to find out?

US (I say this b/c I'm quick to pull the trigger for MRI, typically need a lower imaging form prior to higher level)

What are diagnostic studies for preterm labor/delivery?

US - used to determine length of cervix (normal is 4cm) Exam of cervicovaginal secretions for fetal fibronectin (glycoprotein) Vaginal cultures UA

Diagnostic studies for placenta previa?

US is study of choice - often diagnosed before 20 weeks on US Blood type, cross-match, coag studies with large bore IV if patient is unstable

a leading cause of morbidity for paralyzed patients and the implicaitons of this

UTI... order a UA on all paralyzed patients

FAST Scan

Ultrasound used to evaluate deep, blunt abdominal trauma at the bedside in the ER - Study of choice in trauma setting

What is the classic presentation of an EP?

Unilateral adenexal pain Amenorrhea or spotting Tenderness or mass on pelvic exam Dizziness/syncope GI distress

Clinical features of mastitis?

Unilateral tenderness and heat Fever/chills/flu-like symptoms Usually one quadrant or lobule of breast is affected

What is the cause of endometriosis?

Unknown - may be immunologic, genetic, from retrograde menstruation (most widely accepted cause).

What two acute coronary syndromes are treated the same?

Unstable and NSTEMI

Vtach

Unstable- cardioversion stable- meds or cardioversion

Tx for unstable patient with V.tach who is pulseless?

Unsynchronized cardioversion starting at 100J

This type of brain herniation leads to downward gaze with absence of vertical eye movements and pinpoint pupils

Upward transtentorial herniation

_______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

Hypertension Urgency & Emergency

Urgency: Diastolic BP >120, Systolic >140, No end organ damage Emergency: *End organ Damage*, CNS, CV, Renal, AMI *Increased ICP, HTN, Wide PP, bradycardia,irregular respirations* Pulmonary Edema, Aortic dissection, Eclampsia

Gross hematuria is indicative of?

Urologic injury (Bladder)

How do you diagnose Rubella?

Usually a clinical diagnosis Can do paired sera - get a blood sample now and then in a week. This is usually done in immunocompromised patients.

How do you diagnose contact dermatitis?

Usually clinical diagnosis Patch test (for allergic CD only)

What are common causative organisms of PID?

Usually polymicrobial: N. gonorrhoeae C. trachomatis

Clinical features of cardiogenic syncope?

Usually sudden without prodrome

What is the minimum diagnostic criteria for PID?

Uterine tenderness or Adnexal tenderness or Cervical motion tenderness

What is initial treatment for PSVT in a stable patient?

Vagal maneuvers: Valsalva, ice water bath, carotid sinus massage Adenosine - 6mg IV bolus BB/CCBs - for narrow SVT Procainamide - for wide complex SVT

NEXUS criteria

Validated decision tools that may be used to determine whether cervical spine radiographs are warranted in the trauma pt. - Very sensitive but not specific

What is the definitive treatment for heart murmurs?

Valve replacement

name two abx effective against MRSA (at least in regards to airway issues); hint: linezolid is not one

Vancomycin, clindamycin

How are vascular causes of claudication differentiated from nonvascular causes or arthritis?

Vascular claudication appears after a specific distance and resolves after a specific time of rest while standing

What are 3 causes of syncope?

Vasodepressor (Vasovagal) Orthostatic (postural) hypotension Cardiogenic

Long term pharm therapy for CHF?

Vasodilators: ACEI (to counteract compensatory vessel contriction) Diuretics : Lasix, Bumex (to get rid of excess Na) Inotropic agents : Digoxin (to increase contractility of the heart to improve CO) Beta blockers: to improve EF, reduce LV dilation, reduce dysrhythmias

Black widow spider bite

Venom is neurotoxic Initial bite feels like pinprick and within minutes to hours progresses to severe muscle cramping, generalized abdominal, leg, back pain/spasms

Virchow's Triad

Venostasis Hypercoagulability Vessel Wall injury

What is the rhythm that most people die from?

Ventricular fibrillation

____arrhythmia most frequently results from lower energy AC exposures whereas ____is more common after exposure to higher energy DC.

Ventricular fibrillation; asystole

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

there is one arrhythmia that adenosine is absolutely contraindicated in... what is this arrhythmia

WPW

Management of placenta previa?

Watchful waiting in a stable pt Blood transfusion as needed Patients should abstain from sex C section is the preferred method of delivery

What are the special signs associated with AR?

Water-hammer (corrigan) pulse Quincke sign Duroziez sign Musset sign Austin-Flint murmur

Signs of PVD?

Weak femoral or pedal pulses Aortic, iliac, or femoral bruit Skin changes (atrophy, hair loss, pallor) ED with iliac artery disease (Leriche syndrome) Numbness and tingling

Aortic Aneurysm

Weakened and bulging area in the aorta, true aneurysm (all 3 layers), Genetic, structural, metabolic milieu Age >60, atherosclerosis, HTN, smoking, lipids, other vascular disease *97% Infrarenal*

What is an Aortic aneurysm?

Weakness and subsequent dilation of the vessel wall

72yo female presents w/ unilateral lower extremity edema, similar to a DVT in the past. She recently was on a long bus trip; homan's sign negative. Homan's sign only has good positive predictive value as it is negative in 50% of the cases, but it is probably uneconomical to do a venous duplex US of all patients w/ a similar presentation. what tool should be used to assess the probability that a patient has a DVT

Well's criteria or PERC score (I say this b/c I know that it exists, but I forget to utilize it)

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

How do you diagnose Trich?

Wet mount - will see motile flagellates Pap smear

What is preload? afterload?

What is preload? afterload? Preload: AKA end-diastolic volume (EDV). LV wall stress before contraction. Afterload: AKA end-systolic volume (ESV) Force opposing/stretching muscle after contraction begins. Clinically reflected by SBP.

What is external aburption?

When blood escapes from the uterus and vaginal bleeding occurs

What is Pilonidal disease?

When hair follicle becomes distended with keratin, folliculitis develops which causes edema and occlusion. The follical ruptures and forms a pilonidal abscess which results in a sinus tract that leads to a deep, subcutaneous cavity

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 are common causes of PVCs?

When the myocardium is irritated by factors such as ischemia, electrolyte abnormalities

When do you need surgical management for mastitis?

When there are abscesses or duct ectasia

When should you screen for valvular disease?

When there is a high degree of suspicion when a patient presents with chest pain, heart failure, arrhythmias, congenital abnormalities (ex: Marfans), or hx of rheumatic fever.

What are characteristics of second degree deep burns?

White and dry Tender with or without blisters Most common cause: Hot liquid, steam, flame Heals 14-21 days Some scar May need graft

What are clinical features of a spider bite?

Will feel pain 3 hours after bite and systemic symptoms begin 4-6 hours after bite.

Tx for witness arrest vs unwitnessed arrest?

Witnessed: Defibrillation first Unwittnessed: Begin CPR first

Aortic Dissection workup and Treatment

Work up: CXR, CTA (stable pt), TEE (unstable), Pain control, Control shear forces if hypertensive (esmolol, labetolol, 60 bpm goal HR)-beta blocker plus nitroprusside, Fluids for hypotension, Prepare PRBC, Consult surgeon. Need to Type and Cross 10 units of PRBC

HTN Work up and Treatment

Work-up: CBC, CMP (creatinine), UA, EKG, Trop, CXR, head CT (based on complaint) Exotica Tx: Arrange F/U in majority of pts Lower SBP 25% in 24 hours Labetolol (IV form is fast onset, oral is spontaneous) Nitrates, Hydralazine, ?benzos

Treatment for brown recluse?

Wound cleansing Analgesia

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

What are risk factors for primary dysmenorrhea?

Young age Menarche before 12 Irregular or heavy menses BMI >20 Smoking

in evaluating a patient with chest pain, what is the utility in asking about the character of the pain in regards to when it was at its worst and how it is now?

a crescendo pattern is more suggestive of ACS

OPQRST is good for evaluating chest pain, although severity is pretty much useless (but is more suggestive of aortic dissection if severe). be sure to add size distribution of pain... why?

a small area of involvement, such as the size of a coin, is more suggestive of ACS whereas a larger area is less suggestive

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

the goal of the FAST exam is to assess whether or not there is free fluid in certain locations/compartments... name these locations/compartments.

abdomen, pericardium, thorax; it also assess whether or not there is a pneumothorax

briefly, what is N-acetyl cysteine

acetaminophen toxicity antidote

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

name two severe pediatric airway infections

acute epiglotitis and croup

65yo caucasian female presents to the ED; she was referred by her PCP d/t a sudden spike in BUN/Cr, otherwise asymptomatic. She has a recent hx of squamous cell carcinoma on her anus and started two chemo drugs recently (cisplatin, 5-FU). BUN/Cr was normal two weeks ago, now 65/4.57. Given this info, what is your dx?

acute kidney injury. I say this to highlight a few things: AKI can be asymptomatic (and one definition of this condition is a sudden spike in BUN/Cr). She was referred to a hospitalist which would likely refer to nephrology (I say this to highlight that this is a condition that needs to be tx'd inpatient). Cisplatin in particularly is supposedly known to be hard on the kidneys

___ causes carditis in 50-80% of pts; most common in 6-15 yo

acute rheumatic fever

name the most common narrow complex tachycardia

afib

beta blockers decrease 3 things: HR, BP, name the third

afterload

If the patient meets what criteria, a PE is unlikely

age < 50, HR < 100, SpO2 ≥ 95%, no hemoptysis, no estrogens, no prior h/o DVT or PE, no unilateral leg swelling, no surgery or hospitalization in past 4 weeks

what is a tension pneumothorax

air can enter the pleural space but cannot exit

mainstay of tx in acute epiglottitis

airway management

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

in few words, what is the mgmt of acute supraglotitis

airway mgmt (artificial airway), empiric abx therapy they say that the ADRs of glucocorticoids may outweigh the risks in this condition, bronchodilators (epi) have no utility

mgmt for epiglotitis

airway mgmt is the first thing to consider, usually supplemental oxygen is sufficient may need steroids (i don't think they need to be intubated but i may be wrong); administer abx (etiological agents are Strep or Staph if they have the Hib or HIB vaccine otherwise H. influ); this condition requires hospital admission

tell me everything you know about cardiac tamponade

aka pericardial tamponade. caused by a collection of fluid into the pericardial sac, typically blood. often has a hx of trauma particularly a stab wound. pt will probably have SOB but look for Beck's triad--JVD, muffled heart sounds, hypotension (rarely get all three simultaneously so keep a high index of suspicion in the hx of a stab wound). verify w/ an echo, tx w/ pericardiocentesis (i think that's the technical word, aka pericardial evacuation)

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

name two causes of pancreatitis

alcoholism, gall bladder (alcoholism is more popular, i say this b/c i saw a pt that reported pancreatitis w/o a hx of alcohol consumption and he was perplexed about this but it didn't register with me that gall bladder dz could cause pancreatitis)

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

what is a common atypical presentation of pneumonia that may occur at the extremes of age

altered mental status. i also associate this w/ a UTI, therefore it seems safe to say that altered MS can be a presentation of any bacterial infection, not just UTI

anatomical structure that harbors pneumonia

alveoli

a note about upper abdominal pain

always consider this as possibly referred cardiac origin... ask about ACS ssx

this drug is used to control pretty much all tachyarrhythmias

amiodarone

medical tx for wide complex Vtach

amiodarone... this works for pretty much any Vtach

27yo presents w/ sinus congestion dx'd clinically as sinusitis. technical terminology is acute rhinosinusitis (i forget to distinguish acute from chronic, as told by a 4 week cut off). this has been persisting for the past week or so and thus was deemed to be bacterial. name the tx of choice for this

amox-clav (not just amox)

tx for bacterial sinusitis

amox-clav (not just amox)

what types of bacteria are most commonly associated with cavitations

anaerobes aerbic gram-negative bacilli and staph aureus

why is a tension pneumothorax considered an emergency (so much so of an emergency that it is decompressed presumptively, no time for a CXR)

and quickly progress to respiratory distress

name the types of pneumonia

another slide may say otherwise, trust this one. community acquired, hospital acquired, ventillator acquired, aspiration, PCP

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

how to tx pneumonia in the ICU

antipneumococcal beta-lactam (ceftriaxone or cefotaxime) + either azythromycin or a respiratory tract fluoroquinolone (RTF)

chest pain that radiates between the scapulae is what condition until proven otherwise?

aortic dissection... check the vitals

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

What is the number 1 cause of syncope?

arrhythmias

What is the minor jones criteria for RF?

arthralgia, fever, elevate ESR or CRP, prolonged PR interval

i interviewed a patient in the ED presenting w/ CP. the interview got really long, had a hx of DM, HTN, HLD and was taking "multiple medications." pt reported that he didn't take all of his medications yesterday and I left it at that. where did I go wrong?

ask about specifics regardless of time. need to know which medications he didn't take yesterday--his DM, his HTN, which? specifically which ones of that?

MCC of lung abscess s/s CXR Tx

aspiration polymicrobial (anaerobic) fever, weightloss, fetid/bloody sputum halitosis CXR: cavitation, air-fluid level Tx: clindamycin

what is the presence or absence of cremaster reflex good for

assessing presence/absence of lumbar spine issues (saw this done on a PE of a pt w/ back pain)

spontanous pneumothorax can occur in those that are tall (particularly 20yo men that smoke) or it can result from a lung dz; name a few of these lung dz's

asthma, COPD, cystic fibrosis (know this one for the boards), HIV, TB, Marfan's syndrome (know this one for the boards)

hypertrophic cardiomyopathy Sx

asymptomatic systolic ejection murmur at the LLSB and/or apex (less when supine or squatting)

how long must chest pain persist for it to be considered unstable (at least I think unstable... the one with the worse prognosis)

at least 30 minutes, some will say more than 20

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.

name three common complications of rib fracture

atelectasis, pneumonia, pneuomothorax. a rib fracture itself isn't problematic, but it tends to make patients not want to breath sufficiently deep and they consequently develop these things which can be fatal. also consider to add atelectasis and PNA as compliciations to any patients that isn't breathing deeply

what type of patient may have a physiologic S3

athletes pregnant females healthy young people

acyanotic cardiac defect that results in increased pulmonary blood flow; left-to-right shunts

atrial septal defect

Pediatrics Cardiovascular topic list

atrial septal defect coarctation of the aorta patent ductus arteriosus tetralogy of fallot ventricular septal defect acute rheumatic fever kawasaki disease hypertrophic cardiomyopathy syncope

name three atrial tachyarrhythmias

atrial tachycardia, atrial fibrillation, atrial flutter

What are the treatments for bradyarrhythmias?

atropine, pacing, or epinephrine/dopamine

class of drugs known to cause QT prolongation

atypical antipsychotics

I had traditinoally associated SIRS and Sepsis as a post-op compliation. although it can be d/t that, name some other conditions that can cause it.

autoimmune disorder, pancreatitis, burns, vasculitis, surgery complications, adrenal insufficiency, pulmonary embolism, compilcated aortic aneurysm, cardiac tamponade, anaphylaxis, drug overdose

hypertrophic cardiomyopathy etiology

autosomal dominant w/ incomplete penetrance

abx to use for PNA

azithromycin is the go to. for more complicated cases consider adding augmentin. alternatievly can use levaquin or doxycycline

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

CT is the imaging modality of choice for comatose patients. if the CT is negative, what should you suspect is the cause of the stroke (assuming hypoglycemia and opiate or benzo overdose has been ruled out)

basilar artery thrombosis; confirm w/ MRI

In a patient with possible placenta previa, why should vaginal examination not be performed?

because digital examination could trigger a hemorrhage

acute rheumatic fever Tx

benzathine penicillin salicylates bed rest

alcohol stimulates GABA and when ceased get cathecholamine release. consequently, which class of drug can be used to tx alcohol withdrawal, given its similar mechanism of action?

benzos... there is no specific one (although i'm guessing most use lorazepam or diazepam), and you can give any amount, don't need to worry about an overdose

which class of drug should be given to patients w/ hypertrophic cardiomyopathy?

beta blocker; goal is to increase preload

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

where does air collect in a pneumothorax

between the potential space of the visceral and parietal pleura

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

ask about this medication in any patient that is bleeding

blood thinners to include things like coumadin, heparin, NSAIDS, Eliquis, Xarelto

What does CXR show with pleural effusion? What is the tx?

blunting of costophrenic angle - free pleural fluid on lateral decubitis film; thoracentesis

What will a CXR show for a pleural effusion show?

blunting of costophrenic margins, can see free fluid in LLD position

always ask patients presenting w/ CP about a hx of HA... why?

both can be caused by vasospasm... if you get vasospasm in one area (i.e. heart aka Prinzmetal angina) you're likely to get it elsewhere (i.e. HA) thus hx of migraines reduces likelihood of true angina

the first thing that needs to be assessed in a patient w/ abdominal pain is possibility of surgical abdomen. which two abdominal conditions are candidates for abdominal surgery

bowel obstruction, peritonitis

i know well that miosis is a sign of opioid intoxication. what are some others?

bradycardia, respiratory depression

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

ddx for hemoptysis

bronchitis (i think this is the most common cause), blood thinners, CA (bronchiogenic, larynx), pulmonary embolus, TB (oh crap; i saw a Honduran guy in the ED that mentioned his hemoptysis and I didn't really think anyting of it...)

DKA and HHS allow for hyperglycemia. consequently, one component of tx is the administration of (low dose) insulin, but only if the serum potassium level is high enough so not as to cause hypokalemia. what is the concern of hypokalemia in these patients?

cardiac arrhythmias

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

What nerve injury is associated with a sacral fracture?

cauda equina

what does low magnesium do to an ECG

causes QT prolongation (>440ms until proven otherwise) which can lead to cardiac failure

which type of line needs to be placed in shock patients

central (femoral)

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

in the evaluation of a pt that just had a MVC, check for the seatbelt sign. presence of a seatbelt sign is an indication for what imaging modality?

chest abdomen and pelvic CT according to Jared Campbell

simple definition of angina

chest pain w/ exertion

COPD pateints are at risk for developing a pneumothorax. what is the tx for this pneumothorax?

chest tube insertion. this goes to say that it is not more oxygen, it is not supportive care, it is chest tube insertion

ventricular septal defect Tx

close spontaneously (small defect) surgical repair ~ 4-6 mos (larger defects)

name the labs that must be promptly ordered in patient suspected of having a stroke

coagulation studies (PT, PTT b/c you need to evaluate whether or not they can be given tPA), rapid glucose (their "stroke" may be d/t hypoglycemia)

acyanotic cardiac defect that results in pulmonary venous hypertension

coarctation (narrowing) of the aorta

pt presents w/ new onset seizure. you suspect illicit drug use. which illicit drug can cause seizures?

cocaine

one of the most important facets in evaluation of a patient that has had a seizure is to figure out why they have had a seizure. consequently, inquire about a hx of seizures. if they have a hx, non-compliance can be a common cause. similarly, overdose on certain drugs/compounds can cause seizures. name four of these drugs/compounds

cocaine, theophylline, INH, organophosphates; tx like you would any other seizure

pathogenesis of cardiac tamponade

collection of fluid (blood) in the pericardial space which consequently compresses the heart and thus get poor systemic circulation

what is a pneumothorax

collpased lung

what is the most feared complication of DKA

coma

abx to use for supraglottitis mgmt

combination of a third generation cephalosporin (ceftriaxone, cefotaxime) and MRSA coverage (vancomycin or clindamycin)

three major types of pneumonia

community acquired, hospital acquired, ventillator acquired (I keep forgetting about this one)

CHF - Diastolic dysfunction means a problem with the ____.

compliance or relaxation of the heart during ventricular filling

hallmark symptoms of concussion

confusion and amnesia, less commonly loss of consciousness

name some causes of QT prolongation

congenital, acquired (typically medications, especially atypical antipsychotics, some antiarrhythmics), magnesium depletion, hypokalemia (alcoholics, diarrhea)

MMC of transudative pleural effusion

congestive heart failure (other causes: cirrhosis, nephrotic syndrome, pulmonary embolism)

best way to clean an open wound

copious irrigation with saline under pressure (I say this becuase this was a question and answer on an EOR exam, I observed this in the ED wherein they used a syringe)

Patients with branch retinal artery occlusion and central retinal vein occlusion present with what classic physical exam finding?

cotton wool spots

pericarditis itself isn't too worrisome; what are the feared complications?

could progress to restrictive pericarditis or cardiac tamponade

steeple sign is pathonomonic for which condition

croup

this condition may produce a "seal-like" cough

croup

epiglotitis and croup have a similar presentation and tends to occur in young patients... name some features that distinguishes one from the other

croup produces a barking cough which is absent in epiglotitis, croup tends to produce an inspiratory stridor, epiglotitis tends to produce drooling and pt may assume the tripod position

What is the treatment for retinal detachment to correct the tear?

cryotherapy or photocoagulation

tetralogy of fallot Sx

cyanosis murmur squatting "tet" spells (rapid breathing & increased cyanosis) loud systolic ejection murmur at LUSB, right ventricular heave, S2 is always single

Contrecoup injury

damage to the brain on the side opposite the point of a blow as a result of the brain's hitting the skull

PE and CXR of pleural effusion

dec breath sounds dull percussion decrease tactile fremitus CXR: blunting of the costophrenic angle

Pulsus Paradoxus

decrease in systolic BP of more than 10mmHg with normal inspiration; palpated as weakened pulse with inspiration along with more heart contractions to pulse beats

define pulsus paradoxus

decrease in systolic blood pressure by at least 10mmHg upon inspiration; can occur minimally w/ cardiac tamponade, asthma, obstructive sleep apnea, croup,

synonym for encephalopathy

delirium (although in my opinion delirium is probably a symptom of encephalopathy)

utility of a FAST exam

demonstrates collection of fluid in potential spaces. a negative FAST exam means nothing, so it is used for its positive predictive value. if the first is negative, need to do repeat(s)

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

iniitla tx for Torsades

despite what another slide may say, it seems like shocking is the answer

ECG manifestations of pericarditis

diffuse ST segment elevation

three general classifications for cardiomyopathy

dilated, restrictive, hypertrophic

opiates are known to cause itching, consequently a certain drug can be given when Rx'ing opiates... name that drug

diphenhydramine (Benadryl), but need to consider that this will be very sedating as you're giving a sedating antihistamine in conjunction w/ an opiate which is in and of itself sedating. itching does not apply to Fentanyl

be specific when asking ROS questions... today I learned that this applies to "vision changes." don't merely ask about "vision changes" but elaborate on what you mean. what are some better things to inquire about in regards to vision changes

diplopia, blurry vision

pharmacological agent to induce heart stress in a patient that requires a stress test but can't do it via exercise (contraindications such as OA, diabetic foot ulcer)

dobutamine

there are two forms of chemical stress tests... what are they?

dobutamine echo (positive inotrope; positive if decreased cardiac wall movement), dipyridamole-thalium (aka scintigraphy, positive if decreased uptake)

utility of general impression

don't forget about the power of this in directing your interview... a 36yo presented to the ED w/ chest pain; I was thinking along the lines of costochondritis or pericarditis d/t age but need to first consider whether or not the patient really looks sick

definition of a positive exercise stress test

drop in BP of 10mmHg systolic, at least 2mm of ST depression (dunno in how many leads)

what is one of the most common causes of coma?

drug overdose. thus when you see a comatose patient, you need to suspect that they overdosed on some drugs

Grey-Turner sign

ecchymoses of the flanks associated with fulminant hemorrhagic pancreatitis; very poor prognostic sign

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

electrical tx for wide complex Vtach

electrical shock w/ 200J

What is the treatment for tension pneumo?

emergent needle thoracostomy (2nd intercostal space) to convert it to a simple pneumothorax, followed by chest tube insertion (5th intercostal space) for definitive treatment

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

pts presenting w/ ssx consistent w/ epiglotitis require artificial airway placement. discuss the indications for an endotracheal versus tracheotomy

endotracheal intubation is preferred, if that can't be accomplished do a tracheostomy (ostomy, not otomy)

a patient presenting w/ respiratory distress and drooling is which condition until proven otherwise?

epiglotitis

major ddx for stridor and drooling in a child

epiglotitis (child looks very anxious/toxic), Croup (this will have a cough whereas epiglotitis will not), foreign body aspiration (sudden onset of coughing and choking; the acute nature differentiates from croup)

name two common drugs/hormones that stimulate the SA node

epinephrine, norepinephrine

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

Vasopressin and octreotide, vasodilators, are used in severe cases of ________to constrict dilated vessels.

esophageal variceal bleeding

What will peak flow be in someone with an acute exacerbation of asthma?

exac if < 80% baseline, severe exac if < 50% baseline

Blepharitis is inflammation of the anterior or posterior ____. Treatment is good hygiene and sulfonamide/antistaphylococcal eye ointment or systemic antibiotics.

eyelids

all innocent murmurs are ___ (grade) and ____(timing)

faint: grad 1 - 2/6 early-mid systolic in timing

t/f chest pain that is rapidly relieved by NTG is more likely ischemic.

false. it was previously believed that it was but this is now a misnomer. NTG also relaxes the esopageal sphincter.

most common presenting complaint for MI in elderly

fatigue... not chest pain

acute rheumatic fever minor Jones criteria

fever arthralgia elevated acute phase reactants (ESR, CRP) EKG showing heart block (prolonged PR interval)

kawasaki disease Sx (diagnostic criteria)

fever of 5 days duration w/ at least 4 of following: changes in extremities (erythema/swelling of hands/feet, periungal peeling) polymorphous truncal rash non-purulent bilateral conjunctivitis mucositis (strawberry tongue) changes in lips/oral cavity (erythema, cracking lips) cervical LAD > 1.5 cm

approach to rabies bite

find out what the animal was as not all animals carry rabies; not sure on which do and do not, I think only mammals do minus rabbits. raccoons definitely do. being in a room with a bat is sufficient enough to merit a vaccine and immunoglobulin. rabies vaccine (Rabavert) given at first contact (day zero), 3, 7, 14 days; immunoglobulin also given on first contact but not the remaining three visits for the vaccine doses. ask about ssx (minimally aerophobia, hydrophobia, ascending paralysis). consider that the patient may develop cellulitis, some providers may choose to start abx (I saw utilization of Rocephin and Flagyl)

approach to hemoptysis

first you need to decipher is this is a pulmonary etiology versus gastric etiology. pulmonary is diagnosed generally w/ radiology (start w/ an Xray, may need a CT), gastric requires EGD. Ddx includes BATTLE CAMP B=bronchiectasis or bronchitis A=aspergillous or autoimmune T= TB T=Tumor namely pulmonary L=Lung abscess E=Embolus namely pulmonary, air, placental C=Cystic fibrosis or coagulopathy (are they on blood thinners?) A=AVN M=Mitral valve issue particularly stenosis P=pneumonia

first step in the mgmt of DKA or HHS

fluid replacement w/ isotonic saline

ssx of right heart failure

fluid symptoms in the periphery--JVD, hepatosplenomegaly, DOE, peripheral edema

Anthrax and Yersinia pestis plague are treated with ___or___.

fluoroquinolones or tetracyclines

ddx for RUQ pain

gall bladder issues, lower lobe pneumonia (I keep forgetting about this one), probably others, I just wanted to emphasize PNA

name three causes of pancreatitis

gall stones, alcohol, medication induced (i say this because I knew that gallstone and alcoholic exist, medication induced is the emphasis here)

a piece of advice about gathering HPI

gather all relevant info including pertinent positives and negatives. Think of worst case scenario ddx when interviewing in rule in/out relevant ssx. Try to confine this all to a one trip visit, so think about the workup that you're going to do and whether or not the patient has a contraindication to anything (i.e. metal for MRI, recent use of blood thinners for tPA). One thing that I kept forgetting to ask is about recent hospital admissions, as this will dictate course of abx use

LDL level is a risk factor for angina... specifically what value? What is it if they also have DM?

general population is less than 100, if they have DM then <70

severe HTN tx

get that blood pressure down w/ IV vasodilators such as Nitroglycerin, esmolol, labetolol. this should be done w/ an emergency neurosurgery consult

how is acetaminophen toxicity treated?

give em' the antidote--N acetyl cysteine. if it has been w/in the past 4 hours also give em' some activated charcoal to soak up any tablets that are still floating around in the stomach

airway management is of supreme importance in the management of epiglottitis in kids. given this, what is the utility of an artificial airway

give it to all, not just those w/ a severe obstruction (according to uptodate)

How should fluids be replaced in a patient with DKA?

give several L of NS, switching to ½ NS once hyponatremia corrects, and adding dextrose once serum glucose ↓ to 200 Replace K+ deficits: initial hyperkalemia will rapidly become hypokalemia once insulin is started; may need to supplement K before starting insulin!

initial tx for a tension pneumothorax

go with a clinical diagnosis and do a needle decompression before ordering an Xray as time is of the essence (Tintinalli text)

utility of xray in patients w/ respiratory symptoms thought to be due to foreign body aspiration

good to confirm the diagnosis but cannot be used to exclude it

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

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

number one cause of death in the US

heart attack

general indication for defibrillator

heart failure patients w/ a low EF

Baseline fetal _____ is between 110 and 160 beats/minute.

heart rate

end organ damage can entail four organs; which four?

heart, brain, kidneys, liver

there are four organs that can be assessed for end organ damage, namely in regards to the sepsis continuum. name those four organ and what features indicate end organ damage

heart, brain, liver, kidney heart demonstrated by some sort of cardiomyopathy or vessel involvement such as hypotension brain demonstrated by altered mental status liver demonstrated by LFTs Kidney demonstrated by

which organ systems are primarily affected by electrical shocks

heart, lungs, brain---arrhythmias, respiratory arrest, seizures

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

the general tx for a PE is antiplatelet therapy. however, name the indication for a thrombolytic such as tPA

hemodynamic instability

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

i have a vague understanding that syncope patients need to be evaluated for cause, namely neurogenic versus cardiogenic. name one neurogenic issue that can cause syncope

hemorrhagic stroke

What is the emergent treatment for arterial embolism/thrombosis (pain, pallor, pulselessness, paresthesias, paralysis)?

heparin, emergency embolectomy-thrombectomy to restore blood flow

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 role does vascularity play when deciding whether or not to Rx abx for a wound?

highly vascular areas (i.e. head) don't need abx as desperately as less vascular areas do; also puncture wounds require abx

antihypertensive tx of choice for eclampsia and preeclampsia

hydralazine target 160/100 second line: labetalol delivery is the only definitive tx for preeclampsia

this should be on the ddx for any CKD patient (that is, patient comes in with some complaints and you notice that they have a hx of CKD... you should be thinking of this condition)

hyperkalemia; manifested as peaked T waves on ECG, can also cause arrhythmias if i recall correctly

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 murmur consistent w/ aortic stenosis in a young patient (i.e. 20) is d/t which condition until proven otherwise?

hypertrophic cardiomyopathy

most common cause of sudden cardiac death (SCD) in the young athelete

hypertrophic cardiomyopathy

name two reversible causes of coma

hypoglycemia, opiate overdose

What will BMP show for DKA?

hyponatremia (intracellular shift), hyperkalemia (shift out of cells)

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

How do patients with tension pneumothorax present?

hypotension, distended neck veins, absent breath sounds over affected hemithorax, tracheal deviation

name three causes of pre renal failure

hypovolemic (most common), cardiogenic, distributive

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

pulmonary edema is considered an emergency

i say this b/c i thought it was bad news bears, but not so much of an emergency

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

an artificial airway is indicated for any kid presenting w/ ssx consistent w/ epiglotitits, minimally until age 6 (this is a controversial subject); when should it be used in adults?

if over 50% of the airway is obstructed

what is the rule or relationship regarding DKA and ketones?

if they don't have ketones, it's not DKA (could be HHS). best place to check for ketones is in serum or in urine

some notes about heparin...

if you're also giving warfarin (such as in a heparin-warfarin bridge), always give heparin first (giving warfarin first may cause hypercoagulability). always watch out for HIT (if they get HIT once they should never get heparin again)

What is the tx for retinal detachment?

immediate surgical repair

acute rheumatic fever etiology

immunologic reaction that is a delayed sequela of GABHS infection of the pharynx

overdose patients may be conscious and may have altered mental status... if they do, what is the immediate tx that may reduce this?

in this population need to think about glucose and thiamine, so give em' these

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

WHat causes menieres disease?

increased endolymphatic fluid

physiology of transudative pleural effusion

increased hydrostatic pressure or decreased oncotic pressure of the pulmonary vasculature causes the translocation of fluid pleural:serum protein <0.5 pleural:resum LDH <0.6 pleural fluid LDH <2/3 upper limit of normal

physiology of exudative pleural effusion

increased pleural membrane permeability or impaired lymphatic drainage exudative effusions are protein rish MMC: pneumonia- when adjacent tissue becomes inflamed second MMC: malignant effusions

define cardiogenic pulmonary edema

increased pulmonary capillary wedge pressure secondary to ineffective filling or pumping of the heart. could be d/t CHF, valvular dz (aortic, mitral), arrhythmias, myocarditis

patent ductus arteriosus Tx

indomethacin

coarctation of the aorta Tx

infant in shock > give PGE1 immediately surgical resection transcatheter repair

No nitroglycerin in which kind of MI?

inferior

what causes aspiration pneumonitis

inflammatory chemical injury of the tracheobronchial tree and pulmonary parenchyma produced from the inhalation of regurgitated gastric contents can lead to aspiration pneumonia: n alveolar space infection resulting from the inhalation of pathogenic material from the oropharynx.

25yo male presents to the ED after having a stool broken over his head. obvious laceration on forehead. evaluate this patient (include everything)

inquire about vision disturbances (blurry, double vision), HA (progressive suggestive of hemorrhage which is the thing that you need to be concerned w/ here), changes in motility/speech/memory (amnesia is pathonomonic for concussion), loss of consciousness, be sure to do a neuro exam (cardio and respiratory for all), check orientation to person place time, need to do a CT w/o contrast to rule in/out hemorrhage, need to repair that laceration (should give pain killer for the actual procedure, don't discharge w/ any), need to inquire about tetanus status for all laceration/cut/bite patients (inquire about tingling sensation at site of trauma)

there are a number of severe pediatric airway conditions. when you see a kid in respiratory distress, it is important to differentiate if the noise (wheeze, stridor, etc) is inspiratory or expiratory as this helps to make a differential. name one inspiratory and two expiratory conditions

inspiratory suggests upper airway obstruction such as croup (i'm also guessing acute epiglotitis); expiratory suggests asthma or bronchiolitis

mainstay tx for DKA

insulin and fluids; probably don't need to worry about the specifics but may need to add K and glucose to fluids

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

coarctation of the aorta Sx

irritability failure to thrive difficulty feeding headaches leg claudication CHF shock decreased femoral pulses (neonates) upper extremity hypertension nonspecific ejection murmur at apex

Cardiology

is fun!

What is the treatment for septic arthritis?

joint drainage, systemic antibiotics for 3-4 weeks.

autoimmune disease of inflamed medium-sized vessels (coronary artery aneurysms)

kawasaki disease

yo presents w/ abdominal pain similar to prior episode of kidney stone. suspected kidney stone, what's the workup and tx

labs include CBC w/ diff, CMP, lipase. imaging includes non-contrast abdominopelvic CT (this is giong to be more telling; can do an US in younger patients in whom you want to avoid radiation exposure, order a pregnancy test prior to radiation exposure in pts of child bearing years--not this pt). symptomatic relief w/ opioids (1 mg dilaudid) or NSAIDS (15mg ketorolac for this patient d/t age, otherwise could use a higher dose such as 30). kidney stones also tend to cause nausea, give her some zofran. Generally tx as outpatient w/ pain relief and hydration until stone passes; stone larger than 5mm are less likely to pass and thus consider urology referral, refer if it doesn't pass in 4-6wks.

if you were to order one, just one, test to make the diagnosis of sepsis, what would it be?

lactate. that's lactate, not lactate dehydrogenase. this is even better when ordered sequentially/trending. drawback is that it lacks specificity and thus needs to be combined with clinical judgment

ST Elevations in I, aVL, V4, V5, V6

lateral wall MI, left circumflex artery

define typical chest pain (typical for angina)

left sided chest pain that comes on w/ activity and is relieved (not necessarily resolved) by rest and NTG

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

bicarb supplementation is appropriate minimally in patients w/ DKA or HHS if the arterial pH drops below a certain value... what is this value?

less than 6.90

GCS < ______ you should intubate

less than 8 - "Less than eight, Intubate"

which lab has better sensitivity and specificity for pancreatitis--amylase or lipase?

lipase

minimally two HTN meds that work well in black folks

lisinopril, HCTZ

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

approach to mgmt of stable angina pts

look at the modifiable risk factors... lipid panel, fasting glucose, stress test

i know that benzos are the first line of tx for seizures. namely, which benzo?

lorazepam

ventricular septal defect Sx

loud harsh holosystolic murmur heard best at LSB note: large defects may lead to CHF, pulmonary infections, and delayed growth (failure to thrive)

How should BP be lowered in someone with malignant HTN?

lower DBP by 10% first hour, then 15% next 3-12 hours, IV nitroprusside or lebatalol

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

how to tx a outpatient, healthy person with community acquired pneumonia

macrolide or doxy

foreign body aspiration tends to be difficult to diagnose. what are the implications of this?

maintain a high index of suspicion for someone presenting w/ a respiratory issue

ABCs of emergency med

make sure every patient has a patent airway, is capable of adequately breathing, has adequate circulation... this can generally be established from the general survey

normal QT interval in males and females

males less than 0.43sec females less than 0.45 sec consider it prolonged if it is greater than 0.02 seconds added onto each of these (i.e. greater than 0.45 in males, greater than 0.47 in females)

in my opinion, pretty much any kid presenting w/ respiratory distress gets an xray... why?

many conditions have a similar presentation and this may help to differentiate; minimally may demonstrate thumbprint sign pathonomonic for epiglotitis, may show steeple sign pathnomonic for croup, may demonstrate foreign body indicative of foreign body aspiration (most commonly seen in RLL), may demonstrate pneumothorax

presentation of PCP pneumonia

may have SOB in an AIDS patient, doesn't have the typically lung consolidation but instead has bilateral fluffy infiltrates and a low pulse ox reading

ventricular septal defect; muscular vs membranous which is more common?

membranous

there are two beta blockers that can be used for ACS patients... what are they?

metoprolol, carvedilol

anatomical location at which tension pneumothorax receives needle decompression

mid clavicular space of second intercostal

What is the major jone's criteria for rheumatic fever

migratory arthritis, carditis, valvulitis, CNS involvement (chorea), erythema marginatum, subcutaneous nodules

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

HR range for each: mild, moderate, severe bradyarrhythmia

mild is 40-60, moderate 20-40, severe is less than 20

high voltage electrical shocks/burns are those that are over 1000J. what is one of the complications of this to watch out for

minimally compartment syndrome

physical exam findings of pancreatitis

minimally some epigastric pain and decreased or absent bowel sounds... put this in the ddx for ileus and obstruction

indications for CABG

minimally three vessel dz or dz of LAD (although I'm less sure on this latter)

____ is the most common valvular residual lesions of acute rheumatic carditis

mitral regurgitation

2 flavors of Vtach

monomorphic, polymorphic

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

describe the ECG findings of atrial tachycardia

multiple p waves followed by a QRS complex... this applies to all atrial tachyarrthymias, differentiated based on the rate

most common ADRs of statins

muscle pains, may cause rhabdomyolysis; this may be related to a vitamin D deficiency

while on the ED rotation, I noticed that I was consistently finding tympanny in the upper quadrants of the abdomen... what's the take away from this?

my physical exam skills need some work. the same tympanny I heard on them I hear on me, which tells me that it's not truly tympanic

how is an opioid overdose treated?

narcan/naloxone. you know that it works when patients comes out of coma and may be stuporous, pupils will dilate

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.

approach to patient w/ suspected stroke (i.e. facial droop)... be specific, no broad blanket terms b/c you know that you don't know this

need to assess ABCs first.

workup on a pt w/ severe HTN to assess end organ damage

need to check out the heart, kidnyes, liver, brain, lungs CMP--specifically BUN/Cr, LFTs UA--specifically looking for hematuria, proteinuria Head CT in suspected brain involvement--altered MS, severe HA, focal deficits, visual disturbances CXR for those w/ CP/back pain/SOB--look for mediastinal widening indicative of dissecting aorta, flast pulmonary edema; follow up w/ CT angiography for suspected aortic dissection

severe HTN needs to be assessed for end organ damage as this is what distinguishes an urgency from an emergency. what are some of the featuers to check for in regards to end organ damage?

need to consdier the heart, brain, liver, kidneys (some sources also say lungs) HTN is a major risk factor for an aortic dissection, especially when this elevated so check for mediastinal widening on CXR check for encephalopathy as told by altered MS, HA, visual changes, seizures, vomiting Acute pulmonary edema may occur (especially in hx of trauma, sepsis) as told by SOB, orthopnea, hemoptysis, S3 or S4, JVD, hepatosplenomegaly, CP/pressure ACS AKI as told by decreased urine output/hematuria, back pain, swelling of lower extremities

saw pt in ED in respiratory distress, ABGs ordered demonstrated metabolic acidosis. I had forgotten what the next step is... what is the utility of the anion gap in the assessment of metabolic acidosis

need to determine if a metabolic acidosis is anion gap positive or normal... increased anion gap (and i can't recall what that is) has a cause found in the mnemonic MUDPILES M-methanol U-uremia (secondary to CKD) D-DKA P-propylene glycol I-infection, iron, INH, inborn errors of metabolism L-lactic acidosis E-ethylene glycol S-salicylates normal is other stuff for which i know of no handy mnemonic so forget about it

time is of the essence in evaluating a patient suspected of having a stroke... why?

need to determine whether or not thrombolytics are apporpriate; they're useless after something like 4 hrs of onset of ssx

approach to sore throat

need to figure out if this is d/t an infectious process thus inquire aobut constitutional ssx and how long this has been going on (more than a week more suggestive of bacterial) need to consider other causes such as trauma, neoplasm be sure to inquire about respiratory issues (stridor is indicative of upper respiratory issue)

approach to hemoptysis

need to figure out if this is hemoptysis versus hematemesis. source can generally be determined based on HPI and imaging--xray typically sufficient for hemoptysis, endoscopy for hematemesis mnemonic for etiology: B--bronchitis, bronchiectasis A--Autoimmune, aspergillosis T--TB T--Tumor L--Lung Abscess E--Embolism (has to be a big one) C--Cystic fibrosis A--AVM (arterio venous malformation--I saw one of these on a guy's scrotum, they tend to cause bleeding wherever they occur and they can occur pretty much anywhere) M--Mitral valve P--Pneumonia

46yo white male w/ hx of DM and chronic pancreatitis presents w/ episodes of vomiting that started yesterday, seems suspicious for opioid withdrawal, DKA or exacerbation of pancreatitis. given this information, what is the indication for ordering a troponin?

need to keep a high index of suspicion MI in DM patients as they can have an atypical presentation. this also applies to females and elderly

how is a wide complex Vtach defined

need to look at the start of the R (just before the upward deflection begins) to the nadir of the S (aka the peak); if this is greater than 100ms in one precordial lead (v1-v6) then it's a wide complex

hemorrhagic stroke mgmt

need to stop bleeding so get a prompt neurosurgery consult and they'll handle it. if they're on blood thinners (warfarin) need to give some vitamin K and FFP

low dose IV insulin should be given to patients in DKA or HHS only if serum potassium is above a certain value... what's taht value?

needs to be at least 3.3

Tramadol decreases the seizure threshold... what are the implications of this?

needs to be avoided in seizure pts

what's the relationship between DVT and nephrotic syndrome?

nephrotic syndrome is a hypercoagulable state and therefore patients are more prone to forming a DVT

What is the hallmark s/s of heat stroke?

neurologic dysfunction - frequently associated with cerebral edema

remember to rule out red flag condtiions in patients. this applies to HA. what are the red flag conditions of a pt presenting w/ a HA?

new onset HA in an older patient w/o a hx of HA temporal arteritis neoplasm aneurysm leading to SAH angle closure glaucoma

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

utility of glucocorticoids and bronchodilators (racemic epinephrine) in mgmt of acute supraglottitis according to uptoday

none. the ADRs of glucocorticoids for this condition may outweigh the benefits, no indication for epi (dunno why)

add hypoglycemia to the ddx of altered MS

noted

remember to include CA in the ddx for pain

noted. recall that the vertebrate is the most common site for mets

in evaluating a patient with chest pain, what is the utility in asking about the severity of the pain?

nothing, it's useless according to studies

pt population and timing of Prinzmetal angina

occurs in relatively young patients (<50), especially females, in the morning

utiliity of neck xrays for patient suspected to have epiglotitis

only order if you are unsure of the diagnosis; generally you don't need em' as presentation says it all, may be able to see the epiglotits without xray

although complications of sinusitis are pretty rare, they do occur. what is a major one to consider

orbital cellulitis

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

pts presenting w/ chest pain suspicious for anginal require an EKG w/in first 10 minutes of presentation. what do you do if that one comes back negative?

order another 10 minutes down the road; up to 40% are negative the first go around despite an MI, therefore need a second

why must heparin be given before warfarin

otherwise risk developing warfarin skin necrosis; also makes em' more coagulable briefly

What are signs/symptoms of BV?

pH>4.5 Fishy discharge which is gray or frothy No vulvitis or vaginitis Wet mount will show Clue cells

tx for rib fracture

pain control (opiates). the goal is to get them to breathe sufficiently deep so they don't develop atelectasis, PNA.

when evaluating a patient with chest pain, what is the utility in asking a patient about how long the pain has persisted?

pain that lasted only for a few seconds is seldom ischemic, that which lasts more than 30 minutes suggests either AMI or non-cardiac, that which is in between these two may suggest ischemia

acyanotic cardiac defect that results in increased pulmonary blood flow; left-to-right shunts; connection btw aorta and pulmonary artery

patent ductus arteriosus

all diastolic, holosystolic, late systolic, or continuous murmurs should be considered what

pathologic

Beck's triad

pathonomonic for cardiac tamponade... hypotension, muffled heart sounds, JVD

indications for a chemical stress test opposed to exercise stress test

patient unable to exercise (could be d/t weight, arthritis, whatever) or they have preexisting EKG abnormalities (dysrhtymia, pacemaker, etc)

what are some things that you can expect to find on an EKG of a pt w/ pericarditis

peaked T waves (also hyperkalemia), PR elevation/depression in aVR

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

What is the tx for RF?

penicillin, cephalexin, or azithromycin, and treat all household contacts with + throat cultures

What is the treatment for constrictive pericarditis?

pericardiectomy --- otherwise NSAIDs and Steroids

Pt comes in w/ complaint of recent onset CP. Troponin negative, EKG demonstrates peaked T waves and PR depression in aVR. what does this indicate?

pericarditis... can present w/ peaked T waves, PR elevation/depression in aVR

pt presents to the ED w/ acute onset abdominal pain, he's lying still on the bed and looks toxic. what's the first condition that you think of?

peritonitis... these patients look sick and lie still as movement brings about pain

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

what is Cullen's sign and what it is indicative of?

periumbillical ecchymoses, indicative of hemoperitoneum

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

an unconscious patient w/ no known trigger may be an overdose patient. what physical exam finding may suggest opioid intoxication and what drug should be given to reverse this?

pinpoint pupils. give em' some narcan

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

major ddx for cough and fever (3)

pneumonia, bronchitis, abscess

name a major potential complication of COPD

pneumothorax. this is the most common complication of COPD. major risk factors for pneumothorax are male sex, smoker, mitral valve prolapse, Marfan's.

acute rheumatic fever major Jones criteria

polyarthritis carditis subcutaneous nodules erythema marginatum syndeham chorea

two cardiac arrhythmias that are d/t ischemia until proven otherwise

polymorphic Vtach, Vfib

ST Elevations in V1, V2

posterior wall MI, posterior descending artery

three broad classifications of acute renal failure

pre renal, intrinsic, post renal

32yo female presents w/ what seems to be a kidney stone. you want to do a non-contrast abdominal CT to be sure... what lab must you order prior to this CT?

pregnancy test

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

left heart failure ssx

primarily pulmonary--crackles heard on exam, orthopnea, PND, DOE

all about ectopic pregnancy according to Tintinalli (textbook)

problematic d/t the fact that this is a leading cause of maternal death particularly in the first trimester. risk factors are anything that perturb the fallopian tubes (previous ectopic pregnancy, assisted reproduction techniques, PID, prior tubal surgery, IUD use, in utero diethylstillbesterol exposure). classic triad of symptoms includes pain (abdominal/pelvic?), vaginal bleeding or spotting in a woman w/ amenorrhea (this triad is more common in spontaneous or threatened abortion than in ectopic pregnancy). consider ectopic pregnancy in any woman presenting w/ abdominal/pelvic pain in any woman w/ unexplained ssx of hypovolemia (ectopic pregnancy is often diagnosed incidentally via US). may find adnexal tenderness, cervicitis (think gonorrhoea, chlamydia). Diagnosis typically made by US, other options include laparoscopy, surgery. contrary to my previously held belief, Bhcg levels cannot be used to predict an ectopic pregnancy from an intrauterine. the principle goal is to ensure that IUP is present (this was in bold), typically via US. If there is a clinical suspicion, do a transvaginal US regardless of what the Bhcg level is (ectopic can be present even if Bhcg is very low). surgery is required for cases that can only be diagnosed via laparoscopy. medical tx can be performed w/ MTX

how is bronchitis diagnosed

productive cough w/ an unremarkable xray

pt SOB, CXR ordered demonstrated wedge-shaped infart; this term is pathonomonic for which condition?

pulmonary embolism

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

in evaluating a patient with chest pain, what is the utility in asking about radiation of pain?

radiation (typically down one or both arms or up neck) is suggestive of ACS

in any patient presenting w/ chest pain, what is the utility in asking about radiation?

radiation can suggest ACS (albeit not too strongly in and of itself)

Second Impact syndrome

rapid swelling and herniation of the brain after second head injury that occurs before the symptoms of a previous head injury have resolved

tx for foreign body aspiration

remove it. in my readings it has been via bronchoscopy (rigid bronchoscopy or something to that effect) and they have left it at that. this goes to say that I do not think abx are required.

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

opiates are one cause of a coma. when a patient presents to the ED in a coma, you may not know the cause and drug overdose is a leading cause. what are some of the features on the patient that suggest narcotic overdose?

respiratory depression, constricted pupils (need to consider alternatively use of miotic drugs, argyll robertson pupils d/t syphilis, pontine hemorrhage, organophosphates from insecticides)

is severe sepsis responsive to fluid or unresponsive fluid?

responsive

_____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

two broad classifications for retinal detachment

rhegamatogenous (break in retina), nonrhegmatogenous

heart failure can be divided into right heart or left heart failure. peripheral edema, JVD, hepatosplenomegaly, DOE are ssx of which: left or right?

right

tetralogy of fallot commonly associated w/ ___

right aortic arch DiGeorge syndrome Down's syndrome assoc. w/ AVSD

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

what is the goal in evaluating chest pain patients

rule in/out red flag conditions (PACEPM... pneumothorax, aortic dissection, cardiac tamponade, esophageal rupture, pulmonary embolism, MI), differentiate cardiac origin from others (particularly GI), differentiate stable angina (CP brought on by exertion relieved by rest) from unstable angina (CP brought on by exertion not relieved by rest)

approach to chest pain

rule out the high acuity stuff (i.e. STEMI) so order an EKG if the EKG shows STEMI, they go straight to the cath lab. if they don't havea STEMI move to biomarkers. if biomarkers (troponin) is positive they have an NSTEMI and go straigtht to cath lab,; if negative they have UA which gets a stress test which if positive requires cath lab

tx for dilated cardiomyopathy

same as that of HF (i think this may even be a type of HF)... ACEI, BB, diuresis

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

which abx should be used to tx epiglotitis

second or third generation cephalosporins such as cefuroxime, ceftriaxone

name two feared conditions of a drug overdose

seizures, coma

anytime I see hypotension, I'm inclined to think of volume depletion... name two other things that I need to consider as they are potentially deadly, one more acutely than the other

sepsis (so look for a temperature of less than 36 or greater than 38, WBC less than 4K or greater than 12K, HR greater than 90), cardiac tamponade (check for Beck's triad---hypotension, muffled heart sounds, JVD; usually accompanied by a hx of trauma)

define the difference between SIRS and sepsis

sepsis is SIRS w/ a known source (i.e. an infection)

SIRS, sepsis, severe sepsis, septic shock, multi organ dysfunction syndrome are on a continuum. define what differentiates each fo these

sepsis is SIRS w/ a known source of infection, severe sepsis is sepsis w/ end organ damage of one organ and is responsive to fluids, septic shock is severe sepsis that is not responsive to fluids, MODS is above w/ failing organs (hypotension that cannot be resolved)

define sepsis, severe sepsis and septic shock

sepsis is two or more of the SIRS criteria plus infection; severe sepsis is sepsis plus organ damage or hypoperfusion (kidney failure, CNS changes, DIC, ARDS); septic shock is severe sepsis plus hypotension despite adequate fluid resuscitation (less than 60 systolic without pressors)

define sepsis, particularly how it differs from SIRS

sepsis meets at least two of the SIRS criteria and has an identifable source of infection

approach to severe HTN

severe HTN is that which has a SBP of at least 180 or a DBP of at least 110. pts w/ such as blood pressure need to be assessed for end organ damage as this is the feature that distinguishes the scenario from a HTN urgency from emergency

when assessing pain for severity, it is useless to ask about a scale of 1-10 without a reference. what are some good references to use?

severe pain occurs in kidney stones, delivery of a baby, bony fracture (i had kidney stone in mind, i keep forgetting how severe bone pain is so this also holds utility when inquiring about trauma and suspected fracture)

what differentiates severe sepsis from septic shock?

severe sepsis is responsive to fluid, septic shock is not

in evaluating a patient for chest pain, it is important to rule in/out ACS. what is the utility in asking about that quality of the chest pain (more specifically, what is the utility in knowing if the chest pain is sharp versus dull)?

sharp pain is less suggestive of ACS, dull pain is more suggestive of ACS

fluid repletion w/ normal saline is the first step in mgmt of DKA or HHS. potassium levels also need to be managed, typically using 20-40mEq in normal saline. potassium is only given though if the patient's potassium is outside of a certain range. what is that range?

should be 3.3-5.3

what complication needs to be considered in any seizure patients (aside from etiology)

shoulder dislocation... posterior shoulder dislocations tend to happen w/ seizures, so inquire about shoulder pain

tachy brady syndrome is aka

sick sinus syndrome

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

there is one cardiac arrhythmia which should never be given electricity b/c if you do it could kill them... name that one arrhythmia

sinus tachycardia.... so before you go to shock em', be sure that they don't have a P wave followed by a QRS

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

pericarditis chest pain is typically relieved by positional changes... which position?

sitting up and leaning foward... commit to memory that it is this position in particular and not general positional changes... i say this b/c i interviewed a 36yo F w/ CP in the ED and inquired about positional changes but failed to commit which position in particular

vagal maneuvers have what impact on the heart?

slow it down... the vagal nerve slows down the SA node when activated, hence the utility of vagal maneuvers for slowing down the heart rate

risk factors for CAD

smoking, HTN, HLD (LDL>100, >70 for DM), male gender, age over 60 (this value is debatable), family hx heart conditions, sedentary lifestyle

What three things most commonly cause DIC ("death is coming") ie. disseminated intravascular coagulation?

snake bite, pregnancy, and sepsis

virchow's triad

some form of venous stasis (post surgery can't walk around, 16 hours on a long flight), endothelial injury (smoking, surgery, IV cath), hypercoagulability (acquired d/t OCP or HRT, CA, congenital such as Factor V Leiden)

presence of Howell Jolly Ab suggests what?

splenic dysfunction or asplenia

atrial septal defect Tx

spontaneous closure if small w/n 1st yr of life transcatheter device closure if larger

staph is gram (what) and what is its shape

staphylococcus aureus is a gram positive cocci in clusters note: staph aureus pneumonia is classically associated with post-flu bacterial pneumonia

gram positive cocci in chains that is commonly associated with post-flu pneumonia

streptococcus pneumoniae

HPI of spontaneous pneumothorax

sudden onset pleuritis chest pain typically of affected side, SOB, typically in a tall male that smokes. oxygen sat is nice to look at but only has positive predictive value, sinus tachycardia is the most common presentation (which is also the case for PE)

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.

medical term that means that a condition is essentially psychological (today I saw a pt in the ED w/ an extensive hx of abdominal issues secondary to idiopathic neurological gastroparesis; had numerous visits to the ED, no PCP, poor followup, hx of anxiety and depression. there was no identifiable organic nature to her HPI... what's the diagnosis)

supratentorial (at least this is the term that floats around in the ED, may be the same as somatic conversion?)

tetralogy of fallot Tx

surgical correction for "tet spells" -holding baby in knee chest position (vagal maneuver) -morphine -oxygen -beta-blocker -general anesthesia -sodium bicarbonate

brief loss of consciousness w/ rapid recovery

syncope

what are some common symptoms of a hemorrhagic stroke

syncope, seizure, severe HA (I saw one of these in the ED, the guy was feeling dizzing and had a really bad HA, he also had a SBP of 210)

patent ductus arteriosus Sx (PE)

systolic murmur (newborn) continuous "machinery" murmur best heard below L clavicle widened pulse pressure w/ palpable bounding pulses

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

SIRS criteria

temperature (less than 36, greater than 38), WBC (less than 4K or greater than 12K), HR>90, RR>20 this needs to be combined w/ clinical judgment

name one characteristic of fungal rashes

tend to cause some sort of scaling

tell me everything that you know about hypertrophic cardiomyopathy

tends to occur in young patients (late teens) and is a sudden cause of death. alternatively, may cause SOB d/t obstructed LV outflow tract, which sounds like aortic stenosis (thus aortic stenosis on a young patient is hypertrophic cardiomyopathy until proven otherwise). diagnosis made w/ ECHO, tx w/ BB to increase preload

acute epiglotitis tends to occur in pediatric patients and looks like a number of other respiratory conditions... name at least one key feature that may distinguish it from others

tends to produce drooling as these kids can't swallow; may also expect to see tripod position

cyanotic lesion w/ ductal-dependent pulmonary blood flow; right to left shunt

tetralogy of fallot

when evaluating patients suspected of having had a stroke (or actively having) it is a good idea to inquire about extremity pain... why?

that is atypical for a stroke and suggests an alternate diagnosis

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

everything about epiglotitis (according to Tintinalli text)

the kid will look anxious, tripod position, may be drooling, will not be coughing (this may differentiate it from Croup, diphtheria). it is acceptable to try to view the epiglotits (some people will say don't do think b/c it can injure them but threres no data to support this claim). get an xray to check for thumbprint sign (the white part of the xray will look like a thumb), if this is negative but clinical suspicion remains can directly visualize the epiglotis. airway management is the most important thing, put the kid in an upright position, give oxygen, nebulized racemic epi, intubate, second or third generation cephalosporin (cefuroxime, ceftriaxone) for 7-10 days, steroids

utility of abx in pneumothorax

there is none. don't use abx. i say this because I was unsure as to whether or not they were indicated, they're not.

tell me everything that you know about non-anginal, atypical and typical angina

these definitions hinge on three ssx: 1. left sided chest pain 2. brought about w/ activity 3. relieved (not necessarily resolved) by rest and NTG presence of all three is typical angina; 2/3 is atypical angina; less than 2 is non-anginal

pt presenting w/ CP is asked if they have a hx of migraines and/or Raynaud's... why?

these two things are associated w/ Prinzmetal angina

tx for stable angina patients

they get discharged w/ daily low dose ASA, BB (propranolol) according to Paul Bolin; also get statin of LDL is greater than 100

patients w/ hemophilia A don't form clots well. which clotting study/lab should be ordered for these patients? will it be elevated or decreaesd?

they'll have a prolonged aPTT

beriberi is aka

thiamine deficiency

community acquired pneumonia is treated w/ broad spectrum abx until culture results are back. name the class of med(s)

third generation cephalosporin (ceftriaxone) and a macrolide (azithromycin). alternatively, can go w/ a fluoroquinolone (moxifloxacin)

everything about how to place a chest tube

this goes in around the 4th or 5th intercostal space, midaxillary line; i've only ever seen em' placed in the right side which suggests to me that the right lung is more commonly affected in the case of a pneumothorax. gotta use the sterile technique, so clean the target area, drape, gown up and be sure to wear a face shield b/c this procedure will have airborne blood. inject copious local anesthetic (one doc said that you can't possibly use too much), go pretty deep b/c you want to get to pleural space, make a small incision (~1.5") around the fifth intercostal space going through epidermis, through the subcutaneous fat, down to through fascia then use finger to go the whole way through into the pleural space, dig around in there to clear the way for the tube. place the chest tube directing it towards patient's head until it stops (like to elicit an "ouch"). before placing the tube, you want to place it directly above the rib (the intercostal nerves run below the rib). tie tube down w/ sutures, hook it up to the wound vac, take an Xray (chest tube has radiopaque substance)

a learning scenario: 17mo male w/ hx of asthma presents to ED w/ very labored breathing; tachypnic w/ use of abdominal muscles. Intermittent crying before passing out, oxygen sat 78%. Respiratory therapy was consulted, started racemic epinephrine (no wheezes heard therefore didn't do albuterol b/c that only works on lower airway--always figure out if respiratory issue is upper or lower airway). cbc demonstrated leukocytosis leukocytosis of 34, upper respiratory xray (ordered for suspicion of croup, alternatively epiglottitis) revealed RML PNA. pt was afebrile

this goes to say that WBC level may have some correlation w/ the severity of PNA and may thus impact presentation. the fact that this kid was afebrile raises concern for sepsis (commit to memory that criteria for sepsis is high or low temp). also ordered venous blood gas which revealed metabolic acidosis (low pH, low bicarb) which is kind of bad news bears as it can result in coma and death.

definitive tx for Torsades

this is a polymorphic Vtach which needs to be tx'd w/ a pacer

approach to sinus tachycardia

this is a scary arrhythmia b/c it cannot be shocked (if you shock em' you will kill em'), so you need to think about why they have it, which can be problematic. this could be d/t a PE (most common presenting sign of a PE is sinus tach), volume depletion, hemorrhage to name a few.

fun fact about DOE

this is a sign of minimally heart failure and occurs w/ left or right

what is the utility of pulmonary angiography in PE?

this is considered the gold standard for PE but it is more invasive and a spiral CT does a pretty good job of detection em', so if the spiral CT comes back negative but clinical suspicion remains high then consider pulmonary angiography

two things about general impression

this is important and should be the first thing that you consider to guide your diagnosis (i.e. patient has CP and looks toxic start thinking MI right away rather than asking about other things), get an idea for age because elderly patients may have an abnormal presentation

Briefly define the pathophys of an elevation in cardiac biomarkers

this is indicative of infarction (i wonder about ischemia)

how is acetaminophen poisoning diagnosed?

this is my guess but likely based on the HPI. also check LFTs in which case the AST may be over 1000 (that part is fact)

word of caution for interpretting QT prolongation

this is rate dependent and can thus be masked. algorithms exist to check for it and if i recall correctly this is the corrected QT. this all goes to say that you need to keep a high index of suspicion especially for tachycardia or anything close to it

what is the Centor criteria? What is it good for?

this is used to predict whether or not a sore throat is bacterial in origin, has a terrible positive predictive value (thus if they have these things you should still order a rapid strep to be sure) but a good negative predictive value (thus if they don't have these things they probably do not have strep) criteria includes hx of fever, absence of cough, tonsilar exudate (exudate is not the same is ulcers), anterior cervicular lymphadenopathy

all about ARDS

this looks a lot like CHF--SOB, low oxygen sat, crackles on lungs. this is giong to occur in patients that are sick w/ something serious such as sepsis or some other major insult such as nearly drowning. get a CXR which demonstrates fluid. PCWP will be normal (around 10) but realistically don't need to check this, instead get BNP and echo both of which will be normal which differentiates it from CHF. tx is aimed at resolving the underlying etiology, need to get oxygen sat up using PEEP

pt involved in a MVC comes to ED; hypotensive, afebrile, you notice JVD and hear muffled heart sounds... what do you need to do next?

this sounds a lot like a cardiac tamponade (Beck's triad of hypotension, muffled heart sounds, JVD; typically accompanied by a hx of trauma). next step is to get an echo

two indications for CABG

three vessel dz, left main artery dz

kawasaki disease Dx

thrombocytosis elevated ESR note: seen in 2nd week

utiliity of head CT in pt suspected of having a stroke

to check for things that would contraindicate tPA use such as tumors, bleeds, aneurysms... it's role is not to rule in a stroke as many cannot be seen on CT, thus diagnosis is more so clinical

definitive tx for cardiomyopathy

transplant, but this is unrealistic. point being that this is a terminal condition

What are some drugs associated with Torsades de pointes?

tricyclic antidepressants, erythromycin, ketoconazole, haloperidol, cisapride, disopyramide, pentamidine, sotalol, class I anti-arrhythmics

approach to chest injury

try to get a feel for the force of impact. need to consider the lungs--pneumothorax, contusion, hemothorax, and the heart--pericardial effusion, and the great vessels--aortic dissection (most common in high speed MVC)

this is a oncologicla emergency and thus you should put it on your ddx for any chemo patient

tumor lysis syndrome

tell me everything you know about Prinzmetal angina

typically a female presenting w/ CP w/ no identifiable cause, has been having these episodes, often has a hx of HA (both Prinzmetal and HA can be d/t vasospasm). cardiac markers likely negative, do an ergonavine challenge test, tx w/ CCBs

tx for peritonsilar abscess

typically can tx w/ abx (clindamycin or amoxicillin); severe cases may require drainainge

physical exam findings of pneumothorax

unilateral chest pain and dyspnea, decreased tactile fremitus, hyperresonance on percussion, diminished breath sounds

DVT presentation

unilateral leg swelling, red hot and tender leg (not all are red in my experience); confirm w/ US, tx w/ anticoagulation

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

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

utility of Canadian head CT rules

use this to assess whether or not head imaging is indicated for head trauma

atrial septal defect Sx

usually asymptomatic exercise intolerance when older paradoxical embolism > stroke arrhythmias pulmonary obstructive vascular dz in 3rd or 4th decade systemic ejection murmur in the LUSB (pulmonic area) middiastolic rumble in the RLSB "fixed" wide split S2 right ventricular heave

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

tx for a stable narrow complex tachycardia

vagal maneuver, if that fails do adenosine (6mg, if that fails follow w/ 12mg)

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

four causes of intrinsic renal failure

vascular (dissection, thrombosis, emboli), glomerular (glomerulonephritis), interstitial (acute interstitial nephritis), tubular (acute tubular necrosis which is the most common form)

____ is the most common syncope type in adolescents

vasovagal

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

acyanotic cardiac defect that results in increased pulmonary blood flow; left-to-right shunts; most common congenital heart dz (25%)

ventricular septal defect

pt seen in ED after being hit in the eye w/ a wrench. didn't have any pain; what does this say about corneal abrasion?

very unlikely as this almost always has associated pain

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

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

pt presents to ED w/ complaint of left eye pain that started when she woke up, had contact lenses in overnight. pt is unable to open eyes, has been crying all day d/t pain, reports clear discharge. which exam(s) must be performed on this patient?

visual acuity (not actually practical in her case, but i say this to emphasize that it must be documented on each patient presenting w/ eye pain). also do a slit lamp. HPI of contact lenses in overnight suggests keratitis

traditionally the leading etiological agent of epiglotitis but thanks to modern medicine there's a vaccine against it

was Haemophilus influenza, but now there's an HIB vaccine and now other causes are Staph and Strep

keep a high index of suspicion for SIRS in the ED... what is the SIRS criteria?

whacky temp (less than 36 or greater than 38), HR greater than 90, tachypnea of greater than 20, whacky WBC of less than 4k or greater than 12k or greater than 10% immature neutrophils aka bands

what are the breath sounds associated w/ asthma

wheezing

first thing that you need to determine when you are called to a room d/t heart arrhythmia

whether or not the patient is stable (which probably is true for all scenarios); altered MS, hypotension, cardiac symptoms of ischemia (anginal CP) if pt is unstable get a 12 lead ECG and first check if it's a narrow or wide QRS, regular or irregular (most common irregular is afib)

pt complains of blood coming out of mouth (i.e. hemoptysis). what's the first thing that you need to consider

whether this is truly hemptysis i.e. coughing up blood, rather than throwing up blood

a note about back pain

while gathering the HPI be sure to inquire about hx of CA (regardless of nature of complaint) b/c back is most common site of mets... could also inquire about TB

Prinzmetal angina may cause ST elevation but negative cardiac enzymes... do these patients get cath'd?

yes. ST elevation is an absolute indication for cardiac cath; may do an ergonovine challenge test during cath

considering that opiate overdose is a common reversible cause of coma, is it safe to give this to all patients presenting w/ a coma

yes. ideally these patients will have miosis, respiratory failure, bradycardia, but these are not always present. it is safe to give an opiate antagonist to all comatose patients, this cannot be said of flumazenil