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Case Files EM Flashcards

1
Q

What is the treatment of choice for strep, and how long?

A

PCN for 10 days

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2
Q

What steroids is given to patients with bad strep throat, if clinically indicated?

A

Dexamethasone

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3
Q

What is the classic x-ray sign for epiglottitis?

A

Thumb print sign

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4
Q

What is the treatment for epiglottitis? Abx choice?

A

ENT referral

Cefuroxime

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5
Q

What are the abx of choice for retropharyngealabscess?

A

PCN and metronidazole

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6
Q

What is the usual presentation of Ludwig’s angina?

A

Submaxillary, sublingual, or submental mass with infx s/sx and trismus

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7
Q

What are the abx for Ludwig’s angina?

A

PCN and metronidazole

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8
Q

Which has trismus: peritonsillar abscess, or retropharyngeal abscess?

A

Peritonsillar

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9
Q

What are the abx for peritonsillar abscess?

A

PCN and metronidazole

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10
Q

What are the components of the CENTOR criteria? (4)

A

Cervical adenopathy
Exudates
No cough
Fever

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11
Q

What intervals are troponins obtained to r/o MI?

A

1 (immediately), 4, and 12

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12
Q

What are the components of the TIMI risk score? (7)

A
  • Age over 65
  • H/o CAD
  • 3+ CAD risks
  • Use of ASA in prior week
  • 2+ anginal events in 24 hours
  • ST segment deviation
  • Increased cardiac biomarkers
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13
Q

What is the goal door to balloon time for STEMI?

A

90 minutes

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14
Q

What is the ship and drip method for STEMI?

A

Ship to PCI hospital under 90 minutes away

Start heparin and abciximab

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15
Q

What are the drugs that should be administered to NSTEMI patients?

A 
Beta blockers (if no HF)
LMW heparin
Clopidogrel
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16
Q

What are the drugs that MI patients are started on for life once out of the hospital? (4)

A

ASA
ACEIs
Statins
Beta-blockers

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17
Q

What causes bradyarrhythmias with an MI?

A

If SA node is infarcted from RCA occlusion

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18
Q

What meds should be avoided in patients with a right ventricular infarction?

A

NTG

HIgh dose morphine

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19
Q

What should patients in newly diagnosed A-fib receive upon arrival to the ED?

A

IV and cardiac/pulse ox

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20
Q

What is the most common underlying cause of atrial fibrillation?

A

HTN

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21
Q

Why is it that AF begets AF?

A

Causes degeneration of the electrical and contractile tissue, causing more foci to occur

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22
Q

What is the single most important goal of therapy for treating AF in the ED?

A

Rate control

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23
Q

What is the treatment for hemodynamically unstable AF?

A

Cardiovert

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24
Q

What is the timeframe for cardioversion for AF in the ED? What is done if this is not met?

A
  • Less than 48 hours

- move to anticoagulate for 3 weeks, then convert in 3 weeks, OR TEE + cardiovert

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25
Q

Why is it that pts with WPW should not receive rate control for AF?

A

nodal blocking agents can lead to accelerated conduction down the accessory pathway, leading to VF

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26
Q

How does digoxin slow the HR?

A

Increases parasympathetic tone

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27
Q

When does the 48 hour rule not apply for hemodynamically stable patients in AF? (3)

A
  • Mitral valve disease
  • Severe LV dysfunction
  • h/o embolic stroke
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28
Q

What is the difference between sinus tach and atrial tach, in terms of EKG changes, and treatment?

A

P wave morphology different than sinus

Will not respond to vagal maneuvers or adenosine

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29
Q

What are the EKG findings and the treatment for AVNRT?

A

P waves buried in QRS

Vagal maneuvers/ Adenosine

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30
Q

What are the EKG findings and the treatment for AVRT?

A

Inverted P waves

Vagal maneuvers / adenosine

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31
Q

What are the EKG findings and the treatment for junctional tachycardia?

A

Inverted P waves before or after QRS

Will NOT respond to vagal maneuvers or adenosine.

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32
Q

What are the EKG findings and the treatment for antidromic AVRT?

A

Retrograde P waves may or may not be visible

Avoid beta blockers, CCBs, and adenosine

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33
Q

What is the triad for DKA?

A

Hyperglycemia
Ketosis
Metabolic acidosis

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34
Q

The absence of what lab finding exclude the diagnosis of DKA?

A

No ketones in the urine means not DKA

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35
Q

How long should insulin be delivered to patients in DKA?

A

Until metabolic acidosis resolves

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36
Q

What is the rate of insulin infusion for DKA? At what BG level should dextrose be added?

A

0.1 U/kg/hour

250 mg/dL

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37
Q

When can K be given immediately in DKA?

A

if patients have a low to normal serum K. Otherwise, give NS until normal

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38
Q

What additional electrolyte should be given to patients in DKA to maintain the added K?

A

Mg

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39
Q

What is a major complication of DKA, particularly in children?

A

Cerebral edema

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40
Q

What is the role of using bicarb in DKA?

A

Not effective, even at low pH

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41
Q

What is the temperature needed to diagnose SIRS?

A

x ∉ [36,38]

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42
Q

What is the HR needed to diagnose SIRS?

A

More than 90 bpm

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43
Q

What is the RR or PaCO2 needed to diagnose SIRS?

A

RR over 20

PaCO2 less than 32 mmHg

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44
Q

What is the WBC count needed to diagnose SIRS?

A

Over 12000 or less than 4000

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45
Q

What is the definition of sepsis?

A

SIRS + infection source

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46
Q

What is the definition of severe sepsis?

A

Sepsis + one sign of organ failure OR hypoperfusion

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47
Q

What is the definition of septic shock?

A

Sepsis + hypotension

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48
Q

What is the goal central venous pressure in early goal-direct therapy? what about if mechanically ventilated?

A

8-12 mmHg (over 12 if mechanically ventilated)

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49
Q

What is the goal MAP in early goal-direct therapy?

A

Over 65 mmHg

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50
Q

What is the role of steroids in septic shock?

A

Do not use unless suspect adrenal insufficiency

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51
Q

What are the general ventilator settings to be used in ARDS?

A

Low tidal volumes

PEEP

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52
Q

What causes DIC?

A

ACtivation of both coagulation cascade, and anticoagulant cascade

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53
Q

When should platelets be given in DIC?

A

If less than 5000, or less than 30000 with bleeding

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54
Q

What is the goal central venous oxygen saturation ScvO2) in sepsis?

A

Over 70%

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55
Q

What are the components of the AMPLE mnemonic for history taking in the trauma patient?

A 
Allergies
Medications
Past mhx
Last meal
Events leading up to incident
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56
Q

What are the three stages of shock?

A

Compensated
Progressive
Irreversible

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57
Q

The normal manifestations of shock do not apply to what three categories of patients?

A

Pregnant women
Athletes
Alter autonomic nervous system (e.g. beta blockers)

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58
Q

What characterizes the progressive stage of shock?

A

Arterial pressures fall

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59
Q

What amount of blood loss is characteristic of Classes I-IV of ATLS classifications?

A

Less than 750
750-1500
1500-2000
Over 2000

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60
Q

What HR is characteristic of Classes I-IV of ATLS classifications?

A

Less than 100
More than 100
More than 120
More than 140

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61
Q

What BP (general, not numbers) is characteristic of Classes I-IV of ATLS classifications?

A

Normal
Normal
Decreased
Decreased

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62
Q

What pulse pressure (general, not numbers) is characteristic of Classes I-IV of ATLS classifications?

A

Normal
Decreased
Decreased
Decreased

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63
Q

What RR is characteristic of Classes I-IV of ATLS classifications?

A

12-20
20-30
30-40
More than 40

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64
Q

What urine output is characteristic of Classes I-IV of ATLS classifications?

A

More than 30 mL/h
20-30
5-15
None

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65
Q

What mental status findings are characteristic of Classes I-IV of ATLS classifications?

A

Slight anxious
Mild
Anxious/confused
Lethargic

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66
Q

What are the five areas that should be assessed in every trauma patient?

A 
External bleeding
Thorax
Peritoneal cavity
Pelvis/retroperitoneal
Soft tissue compartments
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67
Q

What organ metabolizes lactate? What is the significance of this?

A

Liver

Liver failure will always have elevated lactate

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68
Q

What is the best clinical estimate of preload?

A

LVEDV

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69
Q

What is the ratio of fluids to blood in hemorrhagic volume resuscitation?

A

3:1

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70
Q

When is transfusion indicated in the hemorrhagic trauma patient?

A

If 2-3L of IVFs do not bring the pt out of shock

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71
Q

True or false: hypotension in a trauma pt is hemorrhage until proven otherwise

A

True

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72
Q

Why is local wound exploration of the chest not a good idea?

A

Procedure itself can penetrate the pleura

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73
Q

Why is it that a chest tube should be placed in a ventilated patient, regardless of the size of the pneumothorax?

A

Tension may result from PEEP

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74
Q

What is the role of CT in detecting diaphragmatic injuries?

A

Only gets bigs ones

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75
Q

What are the s/sx of abdominal trauma that necessitate surgical exploration? (4)

A

Shock
Peritonitis
Gunshot wound
Evisceration of abdominal contents

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76
Q

True or false: a wound that does not penetrate the abdominal fascia may be irrigated and closed without further diagnostic studies

A

True

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77
Q

pt with midline neck tenderness with a negative CT should have what?

A

Flexion/extension plain films

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78
Q

What are the Nexus criteria for neck CTs? (5)

A
  1. No posterior midline TTP
  2. No intoxication
  3. Normal level of alertness
  4. No focal neurological deficits
  5. No painful distracting injuries
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79
Q

What are the s/sx of anterior, posterior, and central cord syndrome?

A 
Anterior = no motor or pain
Posterior = no vibration sense or proprioception
Central = Upper extremity weakness
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80
Q

What are the three steps of the canadian neck CT rule?

A
  1. High risk factors (age over 65, PE findings, or mechanism)
  2. C-spine TTP, ambulatory, or delayed pain
  3. Able to rotate neck
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81
Q

Why is it that neck fractures with neurological compromise may cause respiratory compromise?

A

C3-5 phrenic nerve innervation

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82
Q

What is the role of steroids in the treatment of a spinal cord injury?

A

No longer used 2/2 increased sepsis

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83
Q

True or false: breaks in either the ulna, or the radius are treated closed, whereas if both are involved, then open treatment

A

True

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84
Q

What is the treatment for a colles fracture?

A

Closed reduction

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85
Q

What is the treatment for carpal injuries?

A

Call the surgeon

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86
Q

What amount does epi come in (in terms of mg / dose)?

A

All are generally 1 mg per dose

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87
Q

What is the best way to titrate epi in patients?

A

Add 1 mg of epi to 1 L of fluid, and infuse 1-4 mL per min

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88
Q

What is the treatment for pts on beta blockers in anaphylaxis?

A

Glucagon–activates the adenylate cyclase pathway independent of beta receptor

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89
Q

What is the oxygen saturation target for adults with asthma? Infants? Pregnants?

A

90% in adults and at least 95% in infants, pregnant women, and patients with coexisting heart disease.

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90
Q

What amount of inhaler use is recommended in the ED?

A

In the ED, patients can receive 4 to 8 puffs every 15 to 20 minutes for the first hour of therapy and then every 30 minutes thereafter for 1 to 2 more hours.

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91
Q

What is the role of leukotriene agonists in the treatment of asthma?

A

Only for chronic control

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92
Q

What is the role of Mg in the treatment of asthma?

A

Used in severe cases, and competes with Ca for uptake into the sarcoplasmic reticulum

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93
Q

What is the role of theophylline in the treatment of asthma?

A

None, really.

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94
Q

What is the role of BiPAP in the treatment of acute asthma exacerbation?

A

Should be tried prior to intubation

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95
Q

Besides uncontrollable asthma, what are the four major indications for admission for asthma?

A
  1. new onset
  2. Multiple Hospitalizations
  3. Severe CAD
  4. social/medical issues that impair access
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96
Q

What are the initial ventilator settings for asthma patients?

A

AC mode, 8-10 rate, 6-8 mL/kg

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97
Q

Any trauma to the head, face, neck or spine, should prompt concern for what sort of injury?

A

C-spine

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98
Q

What causes an acquired saddle nose deformity (not syphilis)?

A

Hematoma of septal cartilage causes necrotic breakdown

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99
Q

Name the appropriate suture size: face

A

5-0

6-0

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100
Q

Name the appropriate suture size: scalp

A

3-0

5-0

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101
Q

Name the appropriate suture size: chest

A

3-0

4-0

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102
Q

Name the appropriate suture size: beck

A

3-0

4-0

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103
Q

Name the appropriate suture size: abdomen

A

3-0

4-0

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104
Q

Name the appropriate suture size: extremities

A

4-0

5-0

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105
Q

Name the appropriate suture size: joints

A

3-0

4-0

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106
Q

Name the appropriate suture size: oral

A

3-0

5-0

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107
Q

how long should sutures stay in place for in the face?

A

5 days

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108
Q

Where is the first stitch placed with lacerations through the vermillion border?

A

Exact approximation of the border

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109
Q

What should be done with ear lacerations?

A

Consult ENT of plastics

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110
Q

What may happen if a stitch is placed within the cartilage of the ear?

A

Avascular necrosis

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111
Q

When length of laceration of the buccal mucosa require closure?

A

More than 2 cm d/t food particles, infx

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112
Q

What is the treatment for tetanus, besides supportive?

A

TIG

Tetanus vaccination on opposite side of TIG

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113
Q

How many tetanus shots are needed to be considered fully immunized?

A

3

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114
Q

What is the bacteria classically found in animal and human bites respectively?

A 
Animal = pasteurella
Human = eikenella
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4
5
Perfectly
115
Q

What is the duration of abx for bites for treating infection and prophylaxis respectively?

A

10-14 days if infected

3-5 days for prophylaxis

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116
Q

What is the 1-4 day prodrome of rabies?

A

Nonspecific ILI, followed by hyperactivity

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117
Q

How long should cats/dogs be observed for rabies infection?

118
Q

True or false: postexposure prophylaxis is not needed if someone has already received the vaccine

119
Q

How long does the passive immunity last with rabies IVIG?

120
Q

Why should debridement of venomous bites not be done if there are systemic hematologic symptoms?

A

May be unable to control bleeding

121
Q

What is the treatment for a snake bite in the field?

A

Place constriction bands that DO NOT obstruct arterial flow

122
Q

Bites that are more than (__) hours old are, in general, left open, because of the risk of infection.

123
Q

What is the goal treatment time for an ischemic stroke?

A

60 minutes from walking in the ED

124
Q

What is the timeframe for thrombolytics for strokes?

A

4.5 hours from symptom onset

125
Q

What are the s/sx of a stroke in the territory of the posterior cerebral artery? (3)

A
  • Lack of visual recognition
  • Altered mental status with impaired memory
  • Cortical blindness
126
Q

What are the s/sx of vertebrobasilar stroke (5)?

A
  • Dizziness/vertigo
  • Diplopia
  • Dysphagia
  • Ataxia
  • Ipsilateral CN palsies
127
Q

What are the s/sx of basilar artery occlusion?

A

Quadriplegia and locked in syndrome

128
Q

What are the s/sx of lacunar infarcts?

A

Pure motor or pure sensory symptoms

129
Q

Crossed neurological symptoms generally indicate the lesion is where?

130
Q

What are the early CT findings of an ischemic stroke? (2)

A
  • Loss of the gray-white differentiation 2/2 increased water concentration in ischemic tissues
  • Increased density within the occluded vessel
131
Q

Platelet counts below what are a contraindication to tPA?

132
Q

What are the three things that are absolutely indicated in the work up of syncope?

A

History
Physical
EKG

133
Q

Over what age should syncope patients be admitted?

134
Q

What medical history should syncope patients be admitted?

A

Heart disease

135
Q

What is the upper limit of normal for QTc?

A

440 msec for men

460 for women

136
Q

What patients with a DVT should be treated with anticoagulation?

A

All patients diagnosed with a DVT at or above the popliteal level should be treated with anticoagulation.

137
Q

What test should be ordered in a medium and high pretest probability pt for a DVT respectively, to r/o a DVT if the US is normal?

A 
Medium = d dimer
High = venography
138
Q

What are the components of the Wells criteria? (7)

A
  • DVT suspected
  • Alternative dx is less likely
  • HR over 100
  • Immobilization or surgery in previous month
  • Previous DVT
  • Hemoptysis
  • Malignancy
139
Q

What are the components of the PERC criteria? (8)

A
  • Less than 50
  • pulse over 100
  • SaO2 over 94
  • No unilateral leg swelling
  • No hemoptysis
  • No recent trauma/surgery
  • No prior DVT
  • No hormone use
140
Q

What is the goal when treating hypertensive emergency? Why is it not to lower the BP down to normal levels?

A

Reduce the MAP by 20-25% over the first hour

If too fast, then cerebral ischemia results

141
Q

What are the three first line drugs to treat HTN emergency?

A

Nitroprusside
Labetalol
Nicardipine

142
Q

How is preeclampsia diagnosed in a patient with underlying HTN?

A

if systolic BP has increased by 30 mm Hg or if diastolic BP has increased by 15 mm Hg.

143
Q

What is the pathophysiology of hypertensive encephalopathy?

A

Acute rise in blood pressure causes endothelial cell dysfunction in the brain’s vascular supply leading to cerebral edema.

144
Q

What does HELLP syndrome stand for?

A 
Hemolysis
Elevated 
LFTs
Low
Platelets
145
Q

What is the drug of choice of treating HTN in pregnancy?

A

Hydralazine

146
Q

What is the equation for the cerebral perfusion pressure?

A

MAP - ICP = CCP

147
Q

What is the major metabolite of nitroprusside?

148
Q

What is the major side effect of nicardipine?

A

Reflex tachycardia

149
Q

What is the DOC of lowering BP acutely in pts with renal failure?

A

Fenoldopam

150
Q

What are the two drugs of choice in treating acute HTN in the setting of an MI?

A

Beta blockers

NTG

151
Q

What is the only HTN emergency where rapid and aggressive lowering of blood pressure is indicated?

A

Aortic dissection

152
Q

Why should patients suspected of having acute pancreatitis not undergo immediate CT scan with contrast?

A

Volume depletion = kidney injury

153
Q

What is the most important first step (besides ABCs) in a young child who ingested a foreign object?

A

X-ray to determine location

154
Q

What are the five areas of the GI tract that foreign objects tend to lodge in children?

A
  • Cricopharyngeal narrowing
  • Thoracic inlet
  • aortic arch
  • tracheal bifurcation
  • Hiatal narrowing
155
Q

What is the treatment for food impaction in the esophagus?

A

Endoscopy

Glucagon/NTG to relax esophagus

156
Q

What is the treatment for a coin lodges in a child’s throat?

A

Endoscopy if at the cricopharyngeus

Expectant if impacted less than 24 hours

157
Q

What is the treatment for a battery lodged in a child’s esophagus?

A

x-ray to confirm location, surgical consult for endoscopy if in esophagus

If lower than duodenum, then expectant

158
Q

What is the treatment for a sharp body lodged in a child’s esophagus?

A

X-ray to confirm location, then endoscopic removal

If past duodenum and symptomatic, surgery

159
Q

What is the treatment for drug packet ingestion?

A

NOT endoscopy

Polyethylene glycol to speed movement through GI tract

O/w surgery to remove

160
Q

What is the most common location for FB to become lodged in adults?

A

Distal esophagus

161
Q

What is the treatment for all FBs that are lodged in an airway?

A

Endoscopic removal

162
Q

Why must a button battery be removed ASAP?

A

Risk of esophageal perforation (6 hours) / esophageal burns (4 hours)

163
Q

What is the only FB that you should never endoscopically remove?

A

Packets of drug 2/2 risk of rupture

164
Q

What rectal exam finding may suggest a partial bowel obstruction?

A

Stool or air

165
Q

What is a closed loop obstruction?

A

Blockage that occurs both proximal and distal to the dilated segment

166
Q

What is an open loop obstruction?

A

Intestinal blockage is distal, allowing proximal bowel decompression of obstruction via NG suction or emesis

167
Q

What is a simple (uncomplicated) bowel obstruction?

A

Partial or complete obstruction of the bowel lumen without compromise to intestinal blood flow

168
Q

What is the most common cause of SBOs?

A

Adhesions from previous surgeries

169
Q

What is the most common cause of LBOs?

A

Colorectal carcinoma

170
Q

What is the use of an NG tube in a bowel obstruction?

A

Decompresses air/fluid in proximal segment to prevent progression of bowel distention

171
Q

What happens to intestinal blood flow with a bowel obstruction?

A

Blood flow diminishes, leading to ischemia and possible bacterial invasion

172
Q

Which usually has emesis: large or small bowel obstruction?

173
Q

Which usually has distension: large or small bowel obstruction?

174
Q

Which usually has early cramping pain: large or small bowel obstruction?

A

Small. Later for large

175
Q

What usually causes/exacerbates the pain with a LBO?

A

postprandial

176
Q

True or false: the presence of a recent bowel movement r/o the possibility of an obstruction

A

False–does NOT r/o

diarrhea is frequently reported by patients with progressive large-bowel obstruction.

177
Q

Is localized TTP of the abdomen common in a bowel obstruction?

A

No–suggestive of complications involving an isolated bowel segment

178
Q

Name the clinical implications with the associated abdominal CT finding: dilated small bowel with transition to normal sized bowel

A

Mechanical SBO

179
Q

Name the clinical implications with the associated abdominal CT finding: Over 50% diameter difference between proximal dilated small bowel, and distal small bowel

A

High grade SBO

180
Q

Name the clinical implications with the associated abdominal CT finding: small bows feces

A

Moderate to high grade obstruction

181
Q

Name the clinical implications with the associated abdominal CT finding: intraperitoneal free fluid

A

If found in setting of SBO, high grade SBO

182
Q

Name the clinical implications with the associated abdominal CT finding: thickened small bowel wall

A

High grade obstruction

183
Q

Name the clinical implications with the associated abdominal CT finding: target sign

A

Intussusception

184
Q

Name the clinical implications with the associated abdominal CT finding: swirl sign

A

Internal hernia or volvulus

185
Q

Name the clinical implications with the associated abdominal CT finding: reduced bowel wall enhancement

A

Ischemic bowel wall

186
Q

Name the clinical implications with the associated abdominal CT finding: Pneumatosis intestinalis

A

Ischemic bowel wall/ necrosis

187
Q

What are the first three initial steps of managing a SBO?

A

NPO
IVFs
NG tube decompression

188
Q

What happens to the need to operate with continued bowel obstruction?

189
Q

What should be done if signs of infection are present in a patient with a bowel obstruction?

A

Immediate surgical referral

190
Q

Older patients with large bowel obstruction need more what?

191
Q

What part of the intestines is most likely to have a large bowel obstruction?

A

Splenic flexure

192
Q

More than (__) cm in colon diameter is a risk for colonic perforation?

193
Q

What is the most common cause of a SBO in a patient without a h/o surgery?

194
Q

Persistent pain in a patient with small-bowel obstruction is usually suggestive of what?

A

bowel ischemia or impending bowel necrosis

195
Q

What vectors are responsible for transmitting salmonella/shigella?

A

Eggs and chickens

196
Q

Why should bismuth subsalicylate be avoided in immune compromised individuals with diarrhea?

A

Risk of bismuth encephalopathy

197
Q

What is the abx prophylaxis of choice for patient visiting latin american countries?

198
Q

What is the most common composition of renal stone?

A

Calcium oxalate

199
Q

What is the composition of renal stones 2/2 chronic UTIs?

A

Magnesium ammonium phosphate

200
Q

Fever, pyuria, and severe CVA TTP = ?

A

Pyelonephritis

201
Q

Does the amount of hematuria correlate with the amount of obstruction?

202
Q

What is the imaging of choice for renal stones?

A

Noncontrast CT

203
Q

Why should you be careful with NSAID use in the setting of renal stones?

A

Renal insufficiency (if present) may worsen

204
Q

When is a urological consult needed in the setting of renal stones? (4)

A

If infected
Stones over 7 mm
Inadequate pain control
complete obstruction

205
Q

What causes the HTN associated with renal obstruction?

A

Activation of the RAAS

206
Q

What is the mechanism o f type I, II, III, and IV or renal tubular acidosis?

A 
I = inability to secrete H+
II = decreased proximal reabsorption of HCO3-
III = Inability to secrete NH3
IV = Antagonism of deficiency of aldosterone
207
Q

What are the lab findings for type I, II, III, and IV of renal tubular acidosis? (K, Cl, urine pH)

A

I hypokalemic, hyperchloremic acidosis and urine pH over 5.5

II = hypokalemic, hyperchloremic with urine pH less than 5.5

III = normokalemic, hyperchloremic acidosis with urine pH less than 5.5

IV = Hyperkalemic, hyperchloremic, urine pH less than 5.5

208
Q

What parts of the rectal exam are important to assess in cases of suspected neurogenic bladder?

A

Sphincter tone
Perianal sensation
Bulbocavernosus reflex

209
Q

What are the four major types of medications that can cause urinary retention?

A

Anticholinergics
Beta agonists
Detrusor muscle relaxants
Nacrotics

210
Q

What is the major complication associated with postobstructive diuresis?

A

Electrolyte abnormalities and hypotension

211
Q

What is the first step after a complete H and P for a woman suspected of having PID?

A

Transvaginal US to r/o tubo-ovarian abscess / pregnancy

212
Q

What are the three classic exam findings of PID?

A

Lower abdominal TTP
Adnexal TTP
Cervical motion tenderness

213
Q

What is the usual presentation of a tubo-ovarian abscess?

A

Not much to PID symptoms

214
Q

Why does the DEPP shot decrease the incidence of PID?

A

Lower progesterone = increased cervical mucus thickness, and thus lowers the chance of infection

215
Q

What is the second most common cause of female infertility in the US?

A

Postinfectious tubal 2/2 PID

216
Q

How does a ruptured tubal ovarian abscess present?

A

Shock = surgical emergency

217
Q

What are the non-obvious indications for admission for PID? (3)

A

Tubo-ovarian abscess
IUD presence
Pregnant

218
Q

What is the outpatient therapy for PID?

A

Ceftriaxone + doxycycline w/wo metronidazole

219
Q

What is the general treatment for tubo-ovarian abscesses? What is not?

A

Abx

Not drainage, generally

220
Q

Does the partner need to be treated in cases of PID?

221
Q

True or false: you can generally feel tubo-ovarian abscesses on pelvic exam

A

False–US is indicated

222
Q

Draw out the facial nerve UMN, nucleus, and LMNs

223
Q

If a patient has drooping of the mouth but is able to wrinkle his or her forehead normally, what should be suspected?

A

UMN lesion (e.g. stroke, cerebral hemorrhage, etc.)

224
Q

What portion of ectopic pregnancies are linked to previous salpingitis?

225
Q

What level of hCG is typical of an ectopic pregnancy? An increase of what % of hCG in 48 hours is suspicious for an ectopic pregnancy?

A

1200-1500

under 66%

226
Q

True or false: the level of hCG reliably correlates with the size of the ectopic pregnancy

227
Q

What is the medical therapy for ectopic pregnancies? MOA?

A

IM Methotrexate

Interferes with folinic acid

228
Q

What are the conditions under which methotrexate is optimal for the treatment of an ectopic pregnancy? (3)

A

hCG less than 5000
Fetus smaller than 3.5 cm
No detectable fetal cardiac activity

229
Q

If a woman is not hemodynamically unstable, and an ectopic pregnancy is suspected, when is it appropriate to order and follow hCG, instead of going straight to US?

A

If hCG is less than 2000

230
Q

What is the common surgical treatment for an ectopic pregnancy?

A

Laparoscopic salpingectomy/salpingostomy

231
Q

What, technically, is hyperemesis gravidarum?

A

Intractable n/v that leads to significant volume depletion and electrolyte disturbances

232
Q

What is the antiemetic of choice for pregnant women?

233
Q

What is the treatment for asthma attacks in pregnancy?

A

Same as if not pregnant–albuterol inhalers, inhaled corticosteroids

234
Q

What are the indications for intubating a pregnant patient?

A

PaCO2 of more than 45 mmHg

235
Q

What has been associated with preterm premature rupture of membranes (PPROM)? (3)

A

H/o infections
Multiple gestations
Polyhydramnios

236
Q

What generally happens to ABG with pregnancy?

A

Increased minute ventilation leads to slight respiratory alkalosis, with metabolic compensation

237
Q

True or false: chorioamnionitis always precedes fetal infection

238
Q

What is the “latency” period of PPROM? What is the major concern with this?

A

Time difference between the ROM and the delivery

Major increase in incidence of chorioamnionitis

239
Q

What is the usual history of PPROM?

A

Gushing of fluid, but may be slow leakage

240
Q

What is the test to confirm PPROM?

A

Sterile speculum exam, showing pooling of amniotic fluid and positive nitrazine test of fluid

241
Q

What is the management of PPROM?

A

Admit to hospital with expectant management

242
Q

What is the earliest sign of fetal infection?

A

Tachycardia

243
Q

What is the role of steroids in premature pregnancy?

A

Increases fetal lung maturity

244
Q

What is the treatment of hyperthyroidism in pregnancy?

A

Thioamides and beta blockers

245
Q

What are the major side effects of thioamides?

A

Agranulocytosis

Leukopenia

246
Q

What is the treatment of thyroid storm, including in pregnancy? (5)

A
  • Thioamide
  • KI
  • dexamethasone
  • Propranolol
  • Phenobarbital
247
Q

What is the major complication associated with pregnant pyelonephritis?

A

ARDS and sepsis

248
Q

True or false: pregnant patients with pyelonephritis should almost always be admitted

249
Q

True or false: If an infant has had a rectal temperature more than 38 ° C at home but is afebrile and well appearing in the emergency department, this infant still requires full workup for fever.

250
Q

True or false: If the parent only reports a tactile fever and the infant is afebrile and well appearing in the emergency department, laboratory testing for fever workup is required.

A

False–no lab work up is needed necessarily

251
Q

In a 1-3 month old infant, CSF with greater than or equal to (___) WBC/ mm3 or organisms on Gram stain is considered high risk for SBI.

252
Q

What is the Abx of choice for FWS in 1-3 month old infants?

A

Ceftriaxone

253
Q

What is the relation between SBI and positive RSV test?

A

If RSV positive, 50% decrease in likelihood of SBI

254
Q

What is considered a positive UA in a 1-3 month old infant?

A

More than 9 wbcs

255
Q

What is ciliary flush?

A

Circumferential reddish ring around the cornea

256
Q

What are the two major ocular risk factors for acute closed angle glaucoma?

A
  • Hyperopia (causes shortening of eye and shallow anterior chamber)
  • Age-related lens thickening
257
Q

What types of medications can cause acute closed angle glaucoma? Why?

A
  • Anticholinergics or sympathomimetics

- Causes dilation of iris, and narrowing of the canal of schlemm

258
Q

What is the definitive treatment of acute closed angle glaucoma?

A

Laser iridectomy

259
Q

What is the pharmacologic therapy to reduce intraocular pressures in acute closed angle glaucoma?

A
  • beta blocker (timolol)
  • alpha-2-agonist (apraclonidine)
  • CAI (acetazolamide) or mannitol
260
Q

What is the role of pilocarpine in ACAG?

A

Miotics (pilocarpine) enhance trabecular outflow by constricting the pupil to disrupt the corneal-iris apposition.

261
Q

What are the major difference between chlamydial conjunctivitis, and gonorrheal conjunctivitis?

A

Gonococcal produces copious discharge, whereas chlamydial does not.

Chlamydial is more chronic

262
Q

How does a corneal ulcer appear clinically?

A

White mark

263
Q

True or false; distinguishing a corneal ulcer from abrasion is clinically insignificant

264
Q

How can you differentiate a corneal ulcer from a corneal abrasion?

A

hazy/ cloudy stroma lies beneath an ulcer

clear stroma is deep to most abrasions.

265
Q

What are the s/sx of anterior uveitis? (4)

A

Pain
Blurred vision
Photophobia
Circumcorneal erythema

266
Q

What is endophthalmitis?

A

Inflammation of the vitreous humor (primary or 2/2 hematogenous spread to eye)

267
Q

What is a hypopyon? What is indicated if this is present?

A

a leukocytic exudate, seen in the anterior chamber, usually accompanied by redness of the conjunctiva and the underlying episclera.

Emergent ophthalmological referral

268
Q

What is the difference between orbital and preseptal cellulitis?

A

Orbital will have more painful EOMs, blurred vision, conjunctival injection

269
Q

True or false: subconjunctival hemorrhage are often painful and affect vision

A

FALSE–should be NEITHER

270
Q

What is a hyphema? Treatment?

A

Blood in the anterior chamber

Elevating head to 30 degrees, eye shield, mydriactics

271
Q

What are the s/sx of scleritis? What usually causes it?

A

Severe eye pain, erythema, and decreased vision

Usually 2/2 systemic autoimmune disease

272
Q

What is the most common systemic disease associated with scleritis?

273
Q

What are the indications to do a CT before LP in suspected meningitis? (7)

A
  • AMS
  • Focal neurological deficits
  • Immunocompromised
  • h/o CNS disease
  • New onset seizure
  • Papilledema
  • h/o of evidence of head trauma
274
Q

Name the suspected bacterial cause of meningitis with the following CSF findings:

  • Gram positive diplococci
  • Gram-negative diplococci
  • Pleomorphic gram negative coccobacilli
  • Gram positive rods
A
  • Gram positive diplococci = strep pneumo
  • Gram-negative diplococci = Neisseria meningitidis
  • Pleomorphic gram negative coccobacilli = Haemophilus flu
  • Gram positive rods = listeria
275
Q

What is the abx of choice for meningitis caused by neisseria or strep pneumo?

A

3rd gen cephalosporin

276
Q

Positive india ink stain = ?

A

Cryptococcus neoformans

277
Q

Older or immunocompromised pts are more susceptible to meningitis caused by which organisms? Which abx should they receive?

A

Listeria and H flu

Ampicillin

278
Q

What is the role of steroids in the treatment of meningitis?

A

Reduces inflammation

279
Q

What is the general treatment regimen for all meningitis cases? (3)

A

Vanco + cephalosporin + ampicillin

280
Q

What are the abx for prophylaxis of meningitis in someone who is in close contact to someone who has contracted the disease?

A

fluoroquinolone

281
Q

Should abx treatment be delayed for LP + CT in patients with meningitis?

282
Q

Which two benzos are preferred for the acute treatment of a seizure?

A

Lorazepam

Diazepam

283
Q

What are the second line agents for acute seizure treatment? MOA?

A

Phenytoin or fosphenytoin

Na channel blocker

284
Q

What is the major side effect of phenytoin?

A

hypotension and cardiac dysrhythmias

285
Q

What are the major side effects of phenobarbital in terminating acute seizures? (2)

A

Hypotension and respiratory depression

286
Q

What illicit drug is the most common cause of drug-induced seizures? What is the treatment for this?

A

Cocaine

Benzos

287
Q

Which antidepressant may cause seizures? What is the treatment for this?

A

TCAs

Bicarb

288
Q

What is the cause of isoniazid induced seizures? What, then, is the treatment?

A

Loss of B6 from INH causes a decrease in GABA production

IV pyridoxine is the treatment

289
Q

What is the timeframe for delirium tremens?

A

6-48 hours after the last drink

290
Q

What is the most common metabolic cause of a new-onset seziure? What is the most common cause of Status epilepticus?

A

New onset = hypoglycemia

SE = medication noncompliance

A2 (26 decks)

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