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Sub I Wards > AAICM Cases > Flashcards

AAICM Cases Flashcards

1
Q

Physical Exam Finding of High Positive Predictive Value for Acute Appendicitis

A

RLQ Pain

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2
Q

High Positive Predictive Value for Bowel Obstruction

A

New Onset Constipation

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3
Q

Non-abdominal causes of abdominal pain

A

MI

Pleurisy

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4
Q

Abdominal Pain sx suggestive of surgical/emergent conditions?

A 
Fever
Protracted Vomiting
Syncope/Presyncope
Evidence of GI bleed
Obstipation
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5
Q

Causes of Diffuse Abdominal Pain

A 
Pancreatitis
Bowel Obstruction
Early Appendicitis
Ischemic Bowel
Constipation
Peritonitis
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6
Q

4 Syndromes of Abdominal Pain

A

Peritonitis
Bowel Obstruction
Abdominal Vascular Catastrophe
Nonspecific Abdominal Pain/Medical Conditions

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7
Q

Causes of Peritonitis

A

Localized: acute appendicitis, cholecystitis, diverticulitis, pancreatitis
Generalized: perforated viscus

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8
Q

Causes of Bowel Obstruction

A

Strangulated Hernia

Volvulus

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9
Q

Abdominal Vascular Catastrophe

A

Acute Mesenteric Infarction
Ischemic Colitis
Abdominal Aortic Aneurysm

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10
Q

Nonspecific Abd Pain/Medical Conditions

A 
Drug Induced
Constipation
Acute Gastroenteritis
Acute MI
Lower Lobe Pneumonia
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11
Q

Causes of Abdominal Catastrophes to never miss

A 
Ischemic Bowel
Cholangitis
Bowel Perforation
Splenic Rupture
Ruptured AAA 
Ectopic Pregnancy
Appendicitis
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12
Q

Criteria to admit a patient with abd pain to hospital

A 
Severe pain of unclear cause
Peritoneal Signs
Unstable Vitals
Suspected abd catastrophers
Pyelonephritis/PID with vomiting requiring IV abx
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13
Q

Key feature of Acute Mesenteric Ischemic on Physical Exam

A

Absence of abnormal physical findings in presence of severe acute abd pain

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14
Q

Risk Factors for Acute Mesenteric Ischemia

A 
Cardiovascular Comorbid Conditions
Arrhythmias
Structural Heart DIsease
Hypotension
Atherosclerosis
Hypercoagulability
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15
Q

CT Abd findings suggestive of ischemic colitis

A

Thickened colon with pericolonic stranding

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16
Q

General Approach to Management of Patientw ith Abd Pain

A

Assess Hemodynamic Stability (if unstable consider sepsis, perforated viscus, ischemic bowel -> need imaging and hospitalization)

Fluid Resuscitation
Inform senior and order appropriate imagings
Surgery Consult If Appropriate
*Cautiously use narcotics to avoid masking pain and prevent further assessment

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17
Q

Treatment of Ischemic Colitis

A

Reverse the precipitating cause
Fluid Resuscitation to maintain perfusion pressure
Avoid Vasoconstrictors
If ischemia is mild and no peritoneal signs or sepsis, can manage medically with oral abx and clear liquid diet
Surgery if evidence of bowel ischemia

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18
Q

Causes of Abdominal Pain in Hospitalized Patients

A

Unrelated Conditions first arising in hospital

Direct Consequence of problem related to patient’s illness

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19
Q

Cause of Abd Pain in hospitalized patients arisisng as a direct consequence of problem related to patient’s illness (Post Op Patient in this case)

A 
Mesenteric Ischemia
Ischemic Colitis
Acalculous cholecystitis
Pancreatitis
Ileus
Acute Colonic Pseudo-obstruction
Post Surgical/Procedure COmplications
C-Diff Colitis
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20
Q

Management of Abd Pain in Hospitalized Patient

A

Labs: CBC, UA, CMP, Amylase, Lipase
Imaging: Abdominal X Ray (flat and upright or R lateral decubitus)
Establish Hemodynamic stability

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21
Q

Indications for Ultrasonography in Abd Pain

A

Cholecystitis suspected

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22
Q

Indications for CT Scan for Abd pain

A

Appendicitis, Ischemic Bowel, AAA, Intra-abdominal abscess, retroperitoneal hemorrhage, pancreatitis
Complication of invasive procedure (abd pain within 24-48hrs)
Severe abd pain of unclear etiology

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23
Q

Management of Patient with Abd Pain

A

Aggressive Volume Resuscitation as needed
Decompression with NG Tube (Severe vomiting, ileus, acute colonic pseudo-obstruction or bowel obstruction)
Broadspectrum Abx if infection suspected
Consult Surgery based on suspicion, acuity, and hemodynamic stability

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24
Q

Management of Patient with Abd Pain likely due to Colonic Pseudo Obstruction?

A

Decompression with rectal Tube
Frequent repositioning
Colonic Decompression
Decrease Narcotics Dose

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25
Q

What kind of diet should patients be tolerating by discharge?

A

At least a clear liquid diet prior to discharge

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26
Q

Considerations of pathologies in Abdominal Pain in Women

A 
Tubo-Ovarian Abscess
Ectopic Pregnancy
Ovarian Cysts
UTI
Nephrolithiasis
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27
Q

What should all childbearing age females presenting with abd pain get?

A

Pregnancy Test
Pelvic Exam
Pelvic U/S
Urinalysis

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28
Q

Differential of LLQ Abd Pain

A 
Acute Diverticulities
Ischemic Colitis
Infective Colitis
IBD
UTI
Nephrolithiasis
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29
Q

What imaging should you get if you’re suspecting acute diverticulitis

A

CT with Oral and IV Contrast

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30
Q

40 yr old F with hx of OSA, depression presenting with RUQ pain after eating at a cookout. Described as colicky initially and then constant with nausea and vomiting. Denies fevers, chills, cough, SOB, urinary changes,, smoking, etoh use.

Exam: mild distress due to pain. fever. tenderness to palpation in RUQ and +Murphy sign. negative CVAT

A

DDx:
Acute Cholecystitis
Pancreatitis
Acute Hepatitis

Work Up:
Serum Lipase, LFTs, US Gall Bladder

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31
Q

What are indications a patient should have ultrasound of gall bladder?

A

Colic
Fever
+Murphy Sign

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32
Q

What imaging should you get if worried about acute retroperitoneal bleeding?

A

CT Abdomen

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33
Q

Differential for renal Failure

A

Acute Renal Failure
Chronic Renal Failure
Acute on Chronic Renal Failure

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34
Q

Causes of Prerenal Failure

A

Decreased PO Intake
Vomiting
Infection: causes peripheral vasodilation but kidney is constricted due to increased catecholeamines and ATII
NSAIDs: decreases PGs -> unopposed vasoconstriction of afferent artery -> decreased renal plasma flow
ACE-I: decreases ATII -> decreased resistance in efferent artery -> decreases glomerular hydrostatic pressure
Hypotension

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35
Q

Causes of Intrarenal Failure

A

Pyelonephritis

ATN

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36
Q

Causes of Post-Renal Failure

A

Obstruction

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37
Q

What imaging studies for renal failure?

A

Renal Ultrasound

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38
Q

Winter’s Formula

A

expected pCO2 = 1.5 (HCO3) +8 +/- 2

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39
Q

Hypertensive Emergency

A

Severe HTN (>180/>120 mm Hg) with end organ dysfunction

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40
Q

Hypertensive Urgency

A

Severe HTN without end organ damage

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41
Q

Medications for HTN Emergency in Setting of CHF

A 
IV Loop Diuretic (Furosemide)
IV Vasodilator (Nitroglycerin, ACEi etc)
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42
Q

What medicaiton should you avoid in treating HTN Emergency in someone with impaired renal function?

A

Nitroprusside- can lead to cyanide toxicity

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43
Q

Which anti-HTN drugs should be avoided in HTN Emergency patients with HF?

A

Hydralazine- increases HR

Labetolol/Beta Blocker: decreases contractility

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44
Q

Target Goal in Treating HTN Emergency

A

Rapidly decrease BP over 1-6 hours to diastolic BP of 100-110mmHg

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45
Q

Target Goal in Treating HTN Urgency

A

Slowly decrease BP over 24-48 hours to diastolic BP of 100-110mmHg

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46
Q

Causes of Hypovolemic Hyponatremia

A

Nonrenal: Diarrhea, Vomiting
Renal: Addison’s , Diuretic

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47
Q

Urine Na in nonrenal causes of hypovolemic hyponatremia

A

Diarrhea, Vomiting

UNa: <20mEq/L

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48
Q

Urine Na in renal causes of hypovolemic hyponatremia

A

Addison’s, Diuretic

> 20mEq/L

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49
Q

Causes of Euvolemic Hyponatremia

A

SIADH: PNA, Small Cell Ca, Brain (stroke, subdural hemorrhage, tumor)
Hypothyroidism
Compulsive Water Drinking

50
Q

What is the Una in Euvolemic Hyponatremia?

A

> 20mEq/L

51
Q

Causes of Hypervolemic Hyponatremia

A

CHF, Liver Disease

52
Q

Una in Hypervolemic Hyponatremia

A

<20mEq/L

53
Q

Why is Una decreased in nonrenal causes of hypovolemic hyponatremia?

A

Diarrhea, vomiting
Increased levels of catecholeamines 2/2 dec BP -> Activate RAA System -> inc ATII and Aldosterone -> inc proximal reabsorption of Na

Even though the urine is concentrated, there is little Na in the urine so the concentration is low

54
Q

Why does Uosm increase in hypovolemic hyponatremia?

A

Decreased volume -> stimulate ADH -> reabsorb water from urine

55
Q

How does Addison’s disease cause euvolemic hyponatremia?

A

Decreased glucocorticoids and mineralocorticoids -> renal losses of sodium -> Una>20mEq/L

56
Q

Treatment of Hyponatremia caused by Heart Failure

A

Likely hypervolemic

Treatment: Sodium Restriction, Water restriction, diureses

57
Q

Electrolyte Free Water Equation

A

Urine Volume (V)= (Una + Uk)V/Pna + CH2O

58
Q

Treatment of Hyponatremia due to SIADH

A

Euvolemic Hyponatremia

Tx: Water Restriction

59
Q

Differential Diagnosis of Seizure

A

Exacerbation of Previous Seizure Disorder
Toxic/Metabolites: Hypoglycemia, hyponatremia
Medications: Wellbutrin, Quinolones
Drug Abuse/Withdrawal: etoh, benzo withdrawals
CNS Lesions: Metastatic lesions, SAH, CVA, infection

60
Q

What should you look for in a patient who is seizing?

A 
Hemodynamic Instability?
Really a seizure? 
Localized vs Generalized
Tonic(spasms) vs Clonic (flaccid) vs Tonic-Clonic
Neuro Exam with CNS Lesion?
CNS Infection Sign?
Recent CNS Trauma?
61
Q

Signs of pseudoseizure?

A

Asymmetric Movements, Complex Vocalizations, Rigidity

62
Q

What should you do when assessing patients?

A 
Obtain frequent vitals
Cardiac Monitor
Check Puls Ox
Start O2
Confirm Patency of at least 2 peripheral IV access
63
Q

What are the dangers of prolonged seizures/status epilepticus?

A

Seizures increase susceptibility for further seizures -> inc risk of status epilepticus

64
Q

Actively Seizing Patient. What do you do?

A

Oxygen
Administer IV Benzo (Ativan) 0.02-0.03mg/kg IV
Wait 1 min for response. Give additional Ativan PRN
(Max Dose: 0.1mg/kg)

65
Q

What parts of the history is important in assessing someone wiht a seizure?

A 
Hx of previous seizures
Alcohol/Substance Abuse
Insulin/Meds
Previous Neuro-imaging
Metastatic Work Ups
66
Q

What kind of seizures are related to alcohol withdrawal compared to intracranial lesions?

A

Etoh: Generalized

Intracranial Lesion”: Focal Onset

67
Q

What should be the initial test in a patient who had a seizure?

A

CT Scan
But MRI is preferred due to greater sensitivity and higher yield
If first seizure, get a EEG

68
Q

When is LP indicated in seizure?

A

If suspected of infection or diffuse neoplastic process

69
Q

What medications should be ordered in patient with seizures 2/2 to alcohol/benzo withdrawal?

A

Multivitamin
Thiamine
Folate
*Anticonvulsant not usually indicated if etoh thought to be cause of seizure

70
Q

What happens if patient who just seized seizes again?

A

Get Help
Start Benzos -> If Fail -> Barbiturates (may cause resp failure and necessitate ICU monitoring)
If these fail, will need general anesthesia or propofol

71
Q

What does feculent vomiting indicate?

A

Distal Intestinal Obstruction
Gastrocolic Fistula
Peritonitis

72
Q

What does Bilious Vomiting indicate?

A

Prolonged Vomiting

Obstruction distal to ampulla of vater

73
Q

What does vomiting of undigested food 4-6 hrs after ingestion ndicate?

A

Pyloric Obstruction
Gastroparesis
Achalasia
Zenker’s Diverticulum

74
Q

What does relief of abd pain with vomiting indicate?

A

Peptic Ulcer

75
Q

What does early satiety with vomiting indicate?

A

Gastroparesis

76
Q

What does projectile vomiting indicate?

A

suggests increased intracranial pressure

77
Q

What does early morning vomiting indicate?

A

alcoholism

uremia

78
Q

What does chronic small volume vomiting with maintained weight indicate?

A

Psychogenic vomiting

79
Q

What does missed menses with vomiting indicate?

A

Morning Sickness 2/2 Pregnancy

80
Q

What does abnormal CAGE questions with N/V indicate?

A

Alcoholic Gastritis

Pancreatitis

81
Q

What does vertigo with vomiting indicate?

A

CNS involvement in CN VIII

82
Q

What does orthostatic decrease of pulse and BP indicate in patient wiht N/V

A

Intravascular volume depletion

Tx: IV fluids to prevent organ failure

83
Q

What does absent jugular venous pulse in patient with N/V indicate?

A

intravascular volume depletion

Tx: IVF

84
Q

What does dry mucous membranes with N/V indicate?

A

Dehydration

Tx: IVF

85
Q

What does abnormal abd exam with N/V indicate?

A

Disorders of GI tract and related organs

86
Q

What does Papilledema, Nystagmus, or FND indicate with N/V?

A

Disorder of CNS

87
Q

What tests are useful in DDx of N/V?

A 
Pregnancy Test
BMP
Renal Function Tests
LFTs
Lipase
Abd X Ray
Stool for Occult Blood
EKG
Brain Imaging
88
Q

Complications of N/V?

A 
Dehydration
Metabolic Alkalosis
Hypokalemia
Malnutrition
Vitamin/Mineral Deficiencies
Dental Caries
Aspiration Pneumonitis
Boerhaave's Syndrome
Mallory Weiss Syndrome
89
Q

Medication Classes for N/V

A 
Serotonin Antagonists
Dopamina Antagonists
Corticosteroids
Benzodiazepines
H1 Antagonists
Antimuscarinics
90
Q

Serotonin Antagonists used for N/V

A 
Ondansetron
Dolasetron
Granisetron
Tropisetron
Palonosetron
91
Q

Dopamine Antagonists used for N/V

A

Promethazine
Prochlorperazine
Metoclopramide

**If N/V persists after first dose, then switch to different class

92
Q

Corticosteroids used for N/V

A

Dexamethasone

**If N/V persists after first dose, then switch to different class

93
Q

What should you watch out for when using dopamin antagonists for N/V

A

Dystonia and EPS SE

94
Q

What should you watch out for when using Dexamethasone for N/V?

A

Hyperglycemia

95
Q

H1 Antagonists for N/V

A

Meclizine
Diphenhydramine
Hydroxyzine

96
Q

Antimuscarinics for N/V

A

Scopolamine

97
Q

75y F with hx of HTN and osteoporosis presenting with acute onset of vertigo with severe nausea and vomiting. Dx with acute labrynthitis. Which anti-emetic will you use?

A

Meclizine
Diphenhydramine

Good for patients with migraine, motion sickness, vertigo

98
Q

Patient with Hodgkin’s Lymphoma receiving chemotherapy now wiht severe nausea. Which anti-emetic will you use?

A

Serotonin Antagonists: Ondansetron
Others: Dexamethasone, Promethazine
If not responding to any of the above, then consider Benzo as adjunnct therapy for chemo sx

99
Q

Post-Op patient with Nausea and Vomiting currently on morphine PCA. Which anti-emetic will you use?

A

Decrease or D/C morphine
Add non-opioid adjuvant analgesic

Ondansetron

100
Q

65 y/o F with hx of DM evaluated for nausea of 1 month worsening in intensity. Dx with gastroparesis. Which anti-emetic will you use?

A

Metoclopramide

Watch out for dystonia and EPS

101
Q

Cyclic vomiting syndrome. Which anti-emetic will you use?

A

Supportive Care

Consider TCA in adults

102
Q

Labs/Imaging to order for possible dementia in 80 year old Male

A 
CBC with Diff
CMP
TSH
B12
Folate
RPR
CT Scan without Contrast: r/o subdural hematoma, tumors, etc
103
Q

Treatment of Hypernatremia due to volume depletion?

A

Initially with NS

Then switch to 1/2NS once euvolemic

104
Q

Confusion in elderly patient in hospital

A

Provide environment that does not exacerbate
Allow to sleep at night but awake in day
Restraints only as last resort if patient likely to be hurt
Low dose haldol 0.5mg only when other meds haven’t worked

105
Q

Plasma Glucose in DKA

A

> 250mg/dl

106
Q

Arterial pH in DKA

A

<7.3

107
Q

Serum Bicarb in DKA

A

,< 15mEq/L

108
Q

Features of DKA

A

> 250mg/dl glucose
<7.3 arterial pH
<15mEq/L bicarb
+Ketones

109
Q

Features of HHS

A

> 600mg/dl glucose
Dehydration with serum osm >320 mOsm/kg
Absence of ketoacidosis
AMS

110
Q

Features of Hypoglycemia

A

Blood Glucose <50 mg/DL
Adrenergic Symptoms
Neuroglycopenic Symptoms

111
Q

Adrenergic Symptoms of Hypoglycemia

A

Sweating, Pallor, Tachycardia, Palpitations, Hunger

112
Q

Neuroglycopenic Sx of Hypoglycemia

A

HA, LOC, confusion, somnolence, transient sensory/motor defects, convulsions, coma

113
Q

Metabolic Complications of Diabetes

A

DKA
HHS
Hypoglycemia

114
Q

What would you assess in a patient with diabetes presenting with symptoms?

A

Vitals

Blood Glucose LEvel

115
Q

What labs would you order if suspected DKA?

A

ABG
Serum Bicarbonate
Serum/Urine Ketones

116
Q

Immediate Treatment Measures for DKA

A

IVF

Insulin

117
Q

Do you give Bicarbonate for DKA?

A

Acidosis should resolve with just IVF and insulin

Consider if pH <6.9 and initial IVF and insulin do not reverse acidosis

118
Q

What information regarding diabetes should patients need before discharge?

A

Self Monitoring of Blood Glucose
Prevention, Detection, Treatment of Hypoglycemia
Education on Diet and Exercise

119
Q

Hypoglycemic Patient. What do you start right away?

A

Establish IV access

Give D50 glucose 50cc per IV

120
Q

After initial steps of managing acute hypoglycemia in a patient what would you do for maintenance?

A

Maintenance D10 IVF

*Single IV push of D50 will not be sufficient

121
Q

Which oral Diabetes medications do not produce hypoglycemia?

A

Thiazolidinediones

Metformin

Sub I Wards (3 decks)

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