Associations 3 Flashcards
Physical findings of basilar skull fracture
Raccoon eyes (periorbital bruising)
Battle sign (bruising over mastoid process)
Blood behind TM
CSF rhinorrhea or otorrhea (bad sign)
Signs of increased ICP
Cushing’s triad (HTN, bradycardia, bradypnea)
Papilledema
AMS
Pupil asymmetry
Neck zone I structures
Clavicles to cricoid
great vessels, aortic arch; trachea, esophagus, lung apices; cervical spine, spinal cord and nerve roots
Neck zone II structures
Cricoid to angle of mandible
carotid and vertebral arteries, jugular veins; pharynx, larynx, trachea, esophagus; cervical spine and spinal cord
Neck zone III structures
Angle of mandible to base of skull
salivary and parotid glands; esophagus, trachea; carotid arteries, jugular veins; cervical spine, major cranial nerves
Chest trauma with hyperresonance, decreased breath sounds
Pneumothorax
Chest trauma with paradoxical breathing
Flail chest
Chest trauma with decreased heart sounds, JVD, pulsus paradoxus
Cardiac tamponade
Chest trauma with widened mediastinum, unstable vital signs
Aortic rupture
Potentially fatal injuries w/ chest trauma
Aortic rupture
Tension pneumothorax
Hemothorax
Cardiac tamponade
Sites of significant (>1,500 mL) blood loss frequently not found by PE
Blood left at scene Pleural cavity (CXR) Intra-abdominal (CT/US) Pelvic (CT) Bleeding into thights (x-ray)
Intraperitoneal rupture of bladder
Bladder dome
Usu blunt trauma
Cystoscopy + surgical repair
Extraperitoneal rupture of bladder
Anterior/lateral wall
Usu pelvic fx
Can be treated non-operatively
Transplant + maculopapular rash, abdominal pain, N/V, diarrhea, recurrent infections, easy bleeding
Graft vs host disease (donor immune cells attack host)
+LFT, decreased Ig, platelets; inflammation and cell death on biopsy of skin/liver
Indications for BM transplant
Aplastic anemia
Induction chemotherapy
Leukemia, lymphoma, hematopoietic disorders
Indications for heart transplant
Severe heart disease w/ estimated death w/i 2 years (CAD, congenital defects, cardiomyopathy)
Indications for lung transplant
COPD (esp alpha-1-antitrypsin)
Primary pulmonary HTN
Cystic fibrosis
Estimated death w/i 2 years
Indications for liver transplant
Chronic hepatitis B or C Alcoholic cirrhosis Primary biliary cirrhosis Primary sclerosing cholangitis Biliary atresia Progressive Wilson disease
Indications for renal transplant
ESRD requiring dialysis
Indications for pancreas transplant
DM type I w/ renal failure
C/I to heart transplant
Pulmonary HTN (need concurrent lung transplant) Smoking w/i 6 months Renal insufficiency COPD 70+ Terminal illness
C/I to lung transplant
Smoking w/i 6 months Poor cardiac, renal, hepatic fxn Terminal illness 65+ HIV
C/I to hepatic transplant
Alcoholism
Multiple suicide attempts
Liver cancer
Cirrhosis from chronic hepatitis
Transplant rejection w/i 24 hr
Hyperacute
Antidonor antibodies in recipient (avoid by crossmatching)
Transplant rejection w/i 6 days to 1 year
Acute
Antidonor T-cell proliferation in recipient
Transplant rejection over 1 year later
Chronic
Multiple immune rxns to donor tissue
FEV1/FVC
Normal is 80%
110% may be restrictive
Normal A-a gradient
5-15 mm Hg
Increased A-a gradient
Pulm embolism
Pulm edema
R to L shunt
False normal A-a gradient w/ hypoxia
High altitudes
Hypoventilation
Centor criteria
(Strep throat) Fever Tonsillar exudates Anterior cervical lymphadenopathy Absence of cough (Under 44 yo) 0-1 pt: no cx, no abx 2-3 pt: cx, abx if necessary 4+ pt: empiric abx
Sore throat + amoxicillin = rash
Possible amoxicillin allergy
Possible mononucleosis
Muffled “hot potato” voice + sore throat, fever, lockjaw, drooling + abscess on tonsil or uvula deviation
Peritonsillar abscess
Complications of strep pharyngitis
Acute rheumatic fever (can be prevented w/ abx)
Post-strep glomerulonephritis (not prevented w/ abx)
MCC bronchitis (overall, non-smokers, smokers)
Viral
Mycoplasma
S. pneumo and H. influenzae
PNA + lobar consolidation
Bacterial, typical
PNA + diffuse bilateral infiltrates on CXR
Atypical
MCC PNA in children
Viral (RSV)
MCC PNA in adults
S. pneumo
PNA in cystic fibrosis
Pseudomonas
PNA in sickle cell
S. pneumo
H. influenzae
Klebsiella
PNA in alcoholics or aspiration
Klebsiella
PNA in young adults
Mycoplasma
PNA w/ rust-colored sputum
S. pneumo
PNA w/ currant-jelly sputum
Klebsiella
MCC PNA in neonates
GBS, E coli, Listeria
MCC PNA infants - 5 yo
RSV, S. pneumo
MCC PNA 5-20 yo
S. pneumo, Mycoplasma, Chlamydophila, RSV
MCC PNA 20-60 yo
S. pneumo, Mycoplasma, Viruses, Chlamydophila (<40)
MCC PNA 60+ yo
S. pneumo, H. influenzae, Clamydophila, S. aureus, E. coli, Listeria
Nosocomial PNA causes
S. aureus
Enterobacter
Pseudomonas
Klebsiella
PNA w/ Gram + clusters
S. aureus
PNA w/ Gram + pairs
S. pneumo
PNA w/ Gram - rods
E. coli
PNA w/ Gram + cocci in neonate
GBS
PNA + travel to SW US
Coccidiodomycosis
PNA + caves/bat droppings
Histoplasmosis
PNA + Eastern N. America travel
Blastomycosis
PNA + Central America travel
Paracoccidiomycosis
PNA + immunocompromised (esp <200 CD4 HIV)
Pneumocystis jirovecii
PPD positive at 5 mm
HIV positive
Close contact w/ TB-infected patient
TB signs on CXR
PPD positive at 10 mm
Homeless patients Immigrants from developing nations IVDU Chronically ill patients Health care workers Recent incarceration
PPD positive at 15 mm
Everyone
PPD false negative
Anergic
Malnutrition
Immunocompromised
Sarcoidosis
Asthma + vasculitis
Churg-Strauss
Normal CO2 during asthma exacerbation
Signals impending respiratory failure
ARDS common causes
Aspiration Acute pancreatitis Air or Amniotic embolism Radiation Drug OD Diffuse lung disease DIC Drowning Shock Sepsis Smoke inhalation
ARDS diagnostic characteristics
Acute onset respiratory distress
PaO2:FiO2 ratio <200
Bilateral pulmonary infiltrates
No evidence of cardiac problem
PCWP in pulmonary edema
> 18 = cardiogenic
< 18 = non-cardiogenic (ARDS)
COPD Gold criteria
FEV1 >80% = Gold 1
50-80% = Gold 2
30-50% = Gold 3
<30% = Gold 4
DL50 in COPD
Normal in chronic bronchitis
Decreased in emphysema
Emphysema distribution
Centrilobular in smoking (MC)
Panlobular (alpha-1-antitrypsin deficiency)
Kartagener syndrome
Dextrocardia
Sinusitis (dyskinetic cilia)
Bronchiectasis (dyskinetic cilia)
Dyskinetic cilia
Kartagener syndrome
ADPKD
Causes for bronchiectasis
Unknown in 50% CF Immunodeficiency Dyskinetic cilia (Kartagener syndrome, ADPKD) Pulmonary infections, obstruction Chronic tobacco use
Indications for home O2 in COPD
SpO2 <88% Pulmonary HTN Peripheral edema Polycythemia Goal SpO2 ~90%
SPN characteristics favoring benign lesion
Age < 2 cm
No evidence of lymphadenopathy
(Follow w/ CXR in 3-6 months)
SPN characteristics favoring cancer
Smoker Age >45 New or progressing lesion No calcifications or irregular calcifications > 2 cm Irregular margins (PET, biopsy, resection)
MCC lung cancer in non-smokers
Adenocarcinoma
“S’s” of lung cancer
Squamous cell and small cell lung cancer
Smokers
Central
Squamous cell lung cancer paraneoplastic syndrome
PTHrP - hypercalcemia
Small cell lung cancer paraneoplastic syndromes
ACTH - Cushing
SIADH
Anti Ca channel Abs - Lambert-Eaton syndrome
Pancoast syndrome
Horner syndrome (miosis, ptosis, anhydrosis) Brachial plexus involvement
Superior vena cava syndrome
Obstruction of venous draining through SVC
Head swelling, CNS symptoms
“Honeycomb” or reticular pattern on CXR
Ground glass pattern on chest CT
Interstitial pulmonary fibrosis
Noncaseating granulomas
Sarcoidosis
Granulomatosis w/ polyangiitis (Wegener)
Increased ACE, Ca
Sarcoidosis
Bilateral hilar adenopathy
Sarcoidosis
Arthritis, CP, erythema nodosum (tender red nodules on shins and arms), vision loss, CN palsies, lymphadenopathy
Sarcoidosis
Pneumoconiosis w/ increased risk malignant mesothelioma
Asbestosis (insulation, construction, cars, plumbers)
Pneumoconiosis w/ increased risk TB infection
Silicosis (sand, mining, granite)
Pneumoconiosis w/ progressive fibrosis
Coal worker disease
Silicosis
Pneumoconiosis w/ increased risk of lung cancer
Berylliosis (electronics)
Hampton’s hump (wedge-shaped infarct on CXR)
Rare classic sign of pulm embolism
S1Q3T3
Rare classic EKG sign of pulm embolism
Dx of pulm HTN
Echo (cardiac cath is gold standard)
Pleural effusion labs - Protein and LDH
Transudative vs exudative
Pleural effusion labs - Glucose
Low in TB, malignancy, AI
Pleural effusion labs - pH
Acidic in malignancy, TB, empyema
Pleural effusion labs - Amylase
High in pancreatitis, esophageal rupture, some malignancies
Pleural effusion labs - Triglycerides
High in thoracic duct rupture
Light’s criteria for exudative pleural effusion (exudate if one of three is positive)
Pleural:Serum protein >0.5
Pleural:Serum LDH >0.6
Total pleural LDH >2/3 upper limit of normal serum LDH
Causes of transudative pleural effusion
CHF, cirrhosis, kidney diseases (esp nephrotic)
Causes of exudative pleural effusion
(Inflammation) Infection (bacterial infection, TB), malignancy, vasculitis, pancreatitis, pulmonary embolism
Tall, thin, young man with sudden CP and SOB
Spontaneous pneumothorax
Causes of hemothorax
Trauma, malignancy, TB (or other infection)
Pulm infarction
Pretreatment for rapid sequence intubation
Lidocaine (blunt ICP, use in head injuries)
Fentanyl (blunt pain response and BP elevation)
Atropine (decrease secretions, prevent bradycardia)
Confirm proper placement ET tube
End tidal CO2 (rise following expiration)
Auscultate for b/l lung expansion, no gastric breath sounds
CXR
When to convert intubation to tracheostomy
If intubation is required >3 weeks
Croup cause
Parainfluenza virus types 1 and 2
Acute inflammation of larynx
Croup s/sx
3 months - 5 yo
URI -> barking cough, worse at night, inspiratory stridor (upper airway); steeple sign on CXR
Epiglottitis cause
HiB
Rapidly progressive infection of epiglottis and surrounding tissues that cause airway obstruction
Epiglottitis s/sx
2-7 yo
Dysphagia, sudden high fever, drooling, muffled voice, difficulty breathing, toxic looking; thumbprint sign on CXR
Bronchiolitis cause
RSV
Infection of bronchioles
Bronchiolitis s/sx
MC in winter and spring, children <2 yo
URI, expiratory wheezing, respiratory distress, tachypnea, crackles; hyperinflation of lungs and patchy infiltrates on CXR
Different URI/breath sounds in kids
Stridor - inspiratory, upper airway; croup
Wheezing - expiratory, lower airway; bronchiolitis (2 yo)
Causes of acute stridor in kids
ABCDEFGH Abscess Bacterial tracheitis Croup Diphtheria Epiglottitis Foreign body* Gas (poisonous) Hypersensitivity reaction
Respiratory distress syndrome of newborn cause
24-37 wks gestation (esp <30 wks)
Surfactant deficiency because of lung immaturity that leads to decreased lung compliance, atelectasis
Respiratory distress syndrome of newborn s/sx
Presents w/ respiratory distress w/i 2 days of birth
CXR: diffuse hazy interstitial infiltrates (ground glass appearance), air bronchograms, decreased lung volumes
Lung maturity signs esp in 34-37 wks
Lecithin:sphingomyelin ratio >2
Phosphatidyl glycerol present in amniotic fluid
Transient tachypnea of newborn CXR
Increased lung volumes w/ diaphragm flattening
Prominent vascular markings from hilum (sunburst)
Maybe fluid streaking in interlobular fissures, pleural effusions
Cystic fibrosis pulmonary infection bugs
Pseudomonas
S. aureus
Hepatitis vaccines available
Hep A
Hep B
Hep D (Hep B)
Hep B extrahepatic manifestations
Polyarteritis nodosa Glomerular disease (membranous nephropathy or membranoproliferative GN, adults > children)
Hep C extrahepatic manifestations
Membranoproliferative GN Essential mixed cryoglobinemia Lymphoma Thyroiditis DM Porphyria cutanea tarda Lichen planus
Hepatitis mostly spread through sexual contact
Hep B (also blood)
Hepatitis mostly spread through blood
Hep C (also sexual contact)
Hepatitis with a high maternal mortality in pregnant women
Hep E
Hepatitis that tends to develop chronic state
Hep C (80%) Hep B (90% children, 5% adults)
Hepatitis w/ increased risk of HCC
Hep B (3-5%) (check aFP) Hep C (slight risk)
HBV surface antigen (HBsAg)
Active disease (except window period, 12-20 wks)
HBV envelope antigen (HBeAg)
Active viral replication (high transmissability)
Acute infection (4-12 wks)
Chronic infection w/ active replication
HBV surface antibody (Anti-HBs)
Positive in recovery and vaccination
HBV core antibody (Anti-HBc)
Positive in any history of active disease IgM early (12-20 wks) IgG late (chronic infx or recovery)
HBV serology in acute infection 4-12 wks post-exposure
+HBsAg
+IgM Anti-HBc
+HBeAg
HBV serology in acute infection window period (12-20 wks post exposure)
+IgM Anti-HBc
HBV serology in chronic infection w/ active viral replication (high transmissability)
+HBsAg
+IgG Anti-HBc
+HBeAg
HBV serology in chronic infection w/ lesser viral replication (less transmissability, good prognosis)
+HBsAg
+IgG Anti-HBc
+Anti-HBe
HBV serology in past infection (recovered)
+Anti-HBs
+IgG Anti-HBc
HBV serology in vaccination only
+Anti-HBs
MC salivary gland neoplasm
Pleomorphic adenoma (benign)
Dysphagia w/ solids
Obstructive (peptic strictures, esophageal webs or rings, cancer, radiation/chemical fibrosis)
Iron levels + dysphagia
+Iron can cause esophageal strictures
IDA can be part of Plummer-Vinson syndrome w/ esophageal webs
Dysphagia w/ solids and liquids
NM (achalasia, motility disorders, scleroderma)
Impaired peristalsis, decreased LES relaxation, “bird’s beak” on barium swallow
Achalasia
“Corckscrew” pattern on barium swallow
Diffuse esophageal spasm
Esophageal diverticula locations
Zenker (just above UES)
Traction (midpoint)
Epiphrenic (just above LES)
MC esophageal cancers
Squamous cell (worldwide) Adenocarcinoma (US)
Risk of ischemia/incarceration of stomach in hernia?
Paraesophageal hiatal hernia
Type A gastritis
10%, fundus
Autoantibodies for parietal cells
Assoc w/ pernicious anemia, thyroiditis
Type B gastritis
90%, antrum
H. pylori infection
Assoc w/ PUD, gastric cancer
Pernicious anemia
Autoantibodies destroy parietal cells
Decreased intrinsic factor
Vitamin B12 malabsorption -> megaloblastic anemia
(or loss of terminal ileum -> B12 malabsorption)
Next step for refractory PUD
Think Zollinger-Ellison syndrome
Serum gastrin level
Secretin-stimulation test
PUD, Gastric ulcer
Age >50, H. pylori, NSAID use, 25%
Soon after eating, normal/low gastric acid, high gastrin
Eating may worsen symptoms, cause N/V
PUD, Duodenal ulcer
Younger age, H. pylori (almost all), 75%
2-4 hrs after eating, high gastric acid, normal gastrin
Eating temporarily improves symptoms, worsen later
PUD workup in different patients
40, previous ulcer need EGD w/ biopsy to r/o cancer
Virchow node
L supraclavicular LN
Gastric cancer
Sister Mary Joseph node
Periumbilical node
Gastric cancer
Some GYN cancers
Krukenberg tumor
Metastasis to ovary from GI/breast cancers