CCFP Flashcards
Secondary causes of HTN ABCDES
Atherosclerotic, coarctation of the aorta
Bad kidneys - Renal parenchymal disease
Catecholamines
Drug, Diet
Endrocrine (Hypothyroid, aldosterone, Cushing), EtOH
Fibromuscular dysplasia
sleep apnea, stress
Medications that raise BP
Steroids, NSAIDs, amphetamines, many psychiatric meds - SSRIs, SNRIs, carbamazepine, estrogen/progesterone/androgens, sympathomimetic (decongestant), licorice
What does a lipid panel include
Chol, HDL, LDL, non-HDL, TG
Risks of HCTZ?
Skin cancer non melanoma, possible 4x risk after 3 years
Avoid long acting Chlorthalidone, indapamine b/c of DM2, renal and electrolyte abnormalities
Lifestyle interventions for HTN
Lower salt, exercise, weight loss, reduce alcohol, DASH diet, relaxation –> CBT
HTN Meds to avoid in HTN
alpha blocker alone
Beta blockers if > 60
ACE if black
Risk factors for uterine perforation
breast feeding grand multiparity history of csection nulliparity inexperienced HCP uterine abnormalities postpartum state in breastfeeding women
when should you start various kinds of birth control when removing an IUD?
POP 2 days before, ocp/depo etc 7 days before
contraindications to IUD
pelvic TB, pregnancy, uterine/cervical malignancy, puerperal sepsis, post-septic abortion, unexplained vaginal bleeding, gestational throphoblastic disease with persistently elevated betahcg (decreasing beta is relative), distorted uterine cavity, current PID/gonochlam
mirena: breast cancer, hx of ischemic heart disease, antiphospholipid antibodies, migraine with aura, severe cirrhosis
copper: severe thrombocytopenia
What does SAD PERSONS stand for
Male sex Age <19, >45 Depression Previous attempt Excess EtOH/substances Loss of rational thinking Social supports lackings organized plan no spouse Sickness
What else should you r/o with depression
mania, anxiety (does worry get in the way of your life?), OCD (thoughts/rituals you cannot stop), delusions (special powers/plot against you), hallucinations
When to consider bipolar in absence of mania
age <25 >= 5 episodes family hx hypersomnia hyperphagia/increased weight lability of mood/irritability
first line meds/treatments for PTSD
fluoxetine, paroxetine, sertraline
venlafaxine
CBT
group therapy
first line meds/treatments for OCD
escitalopram, fluoxetine, paroxetine, sertraline
CBT
exposure with response prevention
mimics for depression
hypothyroid, adrenal insufficiency, grief/adjustment disorder, drug use, bipolar, tumor, delirium
SPIKES
setting up perception invitation knowledge emotion strategy, also SAFETY.
SNOPQRST
Safety Next visit Offer Prevention Quit Refer Start Teach
Osteoporosis risk factors
Age > 65 Sex - female post menopausal Alcohol Chronic disease i.e. RA Chronic steroid use Previous fragility fracture Malabsorption/eating disorder Hypogonadism low body weight <60kg for <50yo, fragility #, prolonged use of CS, high risk meds, hypogonadism/premature menopause, malabsorption syndrome, primary hyperparathyroidism, other d/o associated with rapid bone loss and/or fracture
Chronic bronchitis criteria
Chronic bronchitis is defined as a cough with sputum expectoration for at least 3 consecutive months for at least
2 consecutive years
Thalassemia regions
Southeast Asia Africa South America Middle East Carribbean Mediterranean
Broad differential? VINDICATE
Vascular Infectious Neoplasm Drugs Idiopathic Congenital Autoimmune Trauma Endocrine
COPDE sx
cough, purulence, dyspnea, CRP >40
Early warning score i.e. NEWS2
Common ear bugs? what about (complicated) COPD? what about PNA?
Hemophilus,
Moraxella,
Strep pneumonia
(same as for COPD; if complicated add on klebsiella, gram negatives, pseudomonas; same for pneumonia, if comorbid add on staph aureus, if not comorbid, atypicals - mycoplasma and chlamydophila)
COPD tx to prevent exacerbations
Flu/pneumonia shots Action plan to reduce hospital use CPAP? Daily macrolide (azithro, erythro) to decrease exacerbations Exercise Quit smoking Pulmonary rehab Puffers - SABA, LAMA, Respiratory therapy Teach inhaler technique
SNOPQRST
Safety Next visit Offer Prevent Quit Refer Start Teach
Criteria for dx asthma in <6 yo
Wheeze that reverses
it’s not something else
What are the criteria for asthma dx
FEV1/FVC pre <0.75
FEV1 post increases 12%
vs. COPD; post <0.70 and not reversible
Asthma rx pyramid for pre-schoolers
mild - saba
mod - saba + ICS
severe - saba, ICS, oral steroids
Asthma rx pyramid for 6+
mild - LABA + ICS (symbicort) as needed
mod - saba + daily ICS OR as-needed ICS/LABA- formeterol (LTRA as alternative)
mod + - low dose ICS/LABA plus as needed SABA, OR low dose ICS/LABA plus as needed ICS/LABA
mod ++ - med dose ICS/LABA plus as needed SABA, OR low dose ICS/LABA plus as needed ICS/LABA
next! refer for phenotypic investigations + add-on treatment
severe - saba, ICS, LABA, LAMA, LTA, theophylline
**if uncontrolled, saba +/- ICS/LABA on demand
Good asthma control
<1 night time symptoms
<4 use of prn puffer
no activity restrictions, no missed school/work
Risk factors for asthma exacerbations
ICS not prescribed, poor adherence,
GERD, obesity, previous ICU/intubation for asthma, irritants - smoking/allergen/pollution, allergic rhinitis, food allergy, depression, anxiety, pregnancy, FEV1<60%
NSAIDs, betablockers
Frequency of asthma f/up? in pregnancy?
1-3 months after starting treatment then 3-12 months after that; in pregnancy, every 4-6 weeks
Testicular cancer workup and risk facrors BALLS CFP
Bhcg
Alpha fetoprotein
Lop it off
Cryptorchidism
Family hx
Personal hx
Lung cancer screening
age 55-74, 30pk/yr smoke, current or quit <15 years ago. CT annually up to 3 times
Cervical cancer screening indications and nor indications
25-69 every 3 years unless - never sexually active - weakened immune system - symptoms of cervical ca - previous abnormal results - those who do not have a cervix - immunosuppressed CAN stop at age 70 if 3 normal in last 10 years
Skin cancer risk factors
Nevi > 15 older white skin, red hair hx of skin cancer, sun exposure family history multiple sunburns actinic skin damage --> refer if hi risk, skin checks q6 months
skin cancer ABCDE
Asymmetry
Border - gradual, indistinct vs. sharp cut off
Colour variation
Different dermatoscopic structures - pigment network, homogeneous areas, streaks, dots, globules
Colorectal screening
50-74
flex sig q10 or FIT q2 years
Breast Ca screening (5)
1. Screen with mammography every 2-3 y if aged 50-74 y 2. Do not routinely screen those aged 40-49 y 3. Do not screen with magnetic resonance imaging 4. Do not perform clinical breast examination 5. Advise patients not to perform self breast examination
Feb neut
early antibiotic treatment, look for source and consider fungal
stabilize and assess
severe sepsis –> ICU
H Pylori quad therapy
PPI
Bismuth salicylate
Metronidazole
Tetracycline
what is Barrett’s esophagus? prevention,
columnar cells replace squamous;
prevention - high dose PPI and ASA
long term risks of PPIs
fractures
b12 deficiency
dementia
c diff
gallstone RF
female
forty
fat
fertile – on OCP
pancreatitis RF
septra, flagyl HCTZ, ACE progesterone atorva estrogen gall stones ETOH
I = idiopathic
G = gallstones
E = EtOH
T = trauma
S = steroids
M = mumps/malignancy
A = autoimmune
S = scorpion stings … though this probably shouldn’t be your first guess for why your patient has pancreatitis
H = hypertriglyceridemia/hypercalcemia
E = (post) ERCP
D = drugs. Most commonly: thiazides, sulfa drugs, and didanosine
admission criteria - UN
uncontrolled symptoms
unstable
undiagnosed pain esp in elderly, immunocompromised
undischargable i.e. poor social support
fluid for peds
20 mg/kg bolus
maintenance 4/2/1
- 4 ml/kg for the first 10kg
- 2ml/kg for 11-20
- 1 ml/kg 20+
measures to monitor for severe dehydration
weight gfr/creatinine na, k glucose urea
c diff risk factors
abx esp fluoroquinolones previous infxn recent hospitalization older age immunocompromised
c diff pitfalls and rx
don’t test kids <1
rx: vanco po
Can be community acquired
Crohn’s medications
Immune system suppressors:
Azathioprine, nethotrexate, remicade
Anti-inflammatory: steroids (5 asa no longer used)
celiac testing
Anti tissue trans glutaminase + IGA
+/- upper endoscopy, small intestine biopsy
OR endomysial IGA (but this is +++expensive)
if IGa deficiency, DGP IgA and IgG
IBS treatment and medications
Lifestyle: Fluid, fibre, avoid fructose/sugar alcohols
Natural: peppermint oil, laxatives
Rx
- ) Antidepressants (SSRI/TCA)
- ) Anti-spasmodics (hyoscamine)
- ) Anti-cholinergics (bentyl)
- ) Linaclotide - for constipation type
- ) Lotronex - for diarrhea
Restless legs treatment and medications
Lifestyle: iron, mg stretch calves avoid caffeine massage, heat exercise
rx
non ergot dopamine agonists - pramipexole, ropinirole
gabapentin, pregabalin
restless legs dx
sensation or urge to move legs
worse with rest, improves with activity
worse in evening
restless legs risk factors
Etiology
- Primary- genetics, young onset
- Secondary
- fe/mg deficiency
- uremia
- neuropathy
- pregnancy
- varicose veins
- rx (dopamine agonists, lithium, antihistamines, antidepressants)
Associated diseases –ADHD, Parkinsons, DM, renal disease, depression
Tx hyperthyroid
Radioactive iodine uptake (NOT for ladies who are preggers), unless 100% sure it’s graves
B block for symptoms
nodule? >1cm = FNA
don’t treat subclinical hyperthyroid
suspicious features of thyroid nodule
> 1cm
Taller than wide
irregular surface
calcifications within
Treating thyroid storm - BLOCK x 5
Beta blocker - propanalol
Block synthesis - methimazole, propylthiouracil
Block conversion T4 –> T3 propylthiouracil
Block release - iodine
Block Bile - cholestyramine
Treating graves, 3 Rs
Rx - First 4 Blocks - beta blocker, block synthesis, block conversion, block release
Radiation
Removal
Meds to stop when sick/at risk of dehydration
SADMANS
SFU ACE Diuretics Metformin ARBs NSAIDs SGLT2
Three reasons people develop DKA
- acute illness,
- drugs: clozapine, terbutaline, cocaine, lithium, SGLT2
- non compliance
Diabetes complications, micro/macro
micro - retinopathy, neuropathy, nephropathy
macro - atherosclerosis –> CVD, CVA, PVD
Biguanide
metformin
SGLT2 inhibitors
flozins - empagliflozin, canagliflozin
GLP-1R agonists
glutide - semaglutide, liraglutide
DPP4 inhibitors
saxagliptin
sulfonylureas
gliclazide, glyburide
driving 2-4-6 rule diabetes
test BS every 2 hours - if hypoglycemia unawareness
test BS every 4 hours - treat and wait 40 min
keep 6 lifesaver candies in the car for lows
risk factors for hep B
IVDU sex with partner with hep B child born to mother with hep B tattoos blood transfusions living in crowded conditions unimmunized multiple sexual partners MSM occupation prison hx of STIs breastfeeding OK if skin is in intact
medications to treat chronic gout
allopurinol
prboenecid
febuxostat
how to test for Hep C?
anti - HCV (unless known previous hep C)
HCV RNA serum
genotype and subtype
–> spontaneous clearance in 20-45%
how to test for Hep b?
HbsAg - infxn Anti HBS - vaccine Anti HBC --> IgM, total if +ve HBeAg HBV DNA Anti HBe
Mgmt and monitoring hep B
Refer to hepatology Anti virals if severe, cirrhosis U/S q6-12 months for HCC scope every 1-3 years for varices Cirrhosis/fibrosis - fibroscan, Child Pugh
The current approved treatments for HBV are interferon injections (standard or pegylated interferon) or oral nucleoside/nucleotide analogues (entecavir, lamivudine, tenofovir). As oral antivirals are excreted by the kidney, dose adjustments are required in renal failure.
Not all patients with chronic HBV infection need to be treated. The decision to treat depends on several factors including age, serial ALT and HBV DNA levels, and severity of liver disease. Co-infection, particularly with HIV and HCV, needs to be considered when deciding on which medications to use.
HBsAg (surface antigen) indicates infection. Persistence of HBsAg for 6 months or more indicates chronic infection. However, up to 50% of people with extended chronic infection will eventually clear HBsAg. By contrast, those with resolving acute HBV will clear HBsAg several months after initial infection.
Anti-HBs (surface antibody) is a protective antibody produced with recovery from infection or in response to immunization. Over time, titre may decline to undetectable levels. Note: There is a gap of several weeks to months between the disappearance of HBsAg and the appearance of anti-HBs; during this period, anti-HBc total is detectable as a marker of HBV infection.
Anti-HBc IgM (core antibody - IgM) appears early in acute HBV infection and persists for about 6 months. It may also be seen in chronic infection during flares of activity, so clinical/epidemiological correlation is required for interpretation.
Anti-HBc total (total core antibody - IgM and IgG) is a marker of past exposure or current infection. IgG usually persists for life. In low prevalence populations, a finding of isolated anti-HBc may signify a false positive result.
HBeAg (e-antigen) is a marker of viral replication; its presence indicates high infectivity. Implications for liver injury vary with stage of infection (see Module 7 for significance).
Anti-HBe (e-antibody) appears with recovery from acute infection. In chronic infection, the presence of anti-HBe is generally a marker of reduced viral replication, indicating a less infectious state. The implications for liver injury vary with stage of infection (see Module 7 for significance)
Mgmt and monitoring hep C
Refer to hepatology
Treat: interferon or new regimens (harvoni, epclusa)
U/S q6-12 months for HCC
scope every 1-3 years for varices
Cirrhosis/fibrosis - fibroscan, Child Pugh
NAFL vs NASH, and treatment?
NASH = NAFL + hepatitis (increased ALT/AST)
= signs of inflammation
NAFL - no inflammation or fibrosis = STEATOSIS
Rx - stop EtOh, weight loss, lipid control, DM control, if fibrosis >2 consider vitamin E
Ankylosing Spondylitis features
low back/SI pain stiffness
worse w/ rest, improves w/ movement
worse at night
30 minutes + for morning stiffness to recede
weight loss, fatigue
chest pain – from insertion into sternum
enthesis i.e. plantar fasciitis, achilles tendonitis
anemia
uveitis
aortitis
heart block
what is Schober’s test
find L5, measure 10cm above and 5cm below = 15cm
if <20cm when bending forward = restrictive
investigations for Ankylosing Spondylitis
ESR, CRP
HLA b27
spine xray or MRI for early changes
mgmt Ank spond
nsaids steroids for flares - oral, IM, into joint anti TNF monoclonal antibody physio no smoking bisphosphonates if osteoporosis
Back pain physical exam
ALWAYS: numbness, weakness, pedal pulses, neuro exam
Lower limb Myotomes memory aid
L1/L2 buckle my shoe - hip flexion
L3/L4 kick the door - knee extension
C5/6 pick up sticks - biceps
C7/8 - shut the gates
Dermatomes memory aid
L4 down on all 4s - knees to first toe
L5 middle toes
S1 pinky toe
joint red flags
hot boggy AM stiffness PM night pain extra-articular symptoms? think genital infection, vasculitis, systemic illness
ADHD medication classes
Stimulants - methylphenidate (concerta, biphentin, ritalin), amphetamine (vyvanse, adderall)
SNRI - Atomoxetine
Alpha receptor antagonist - Guanfacine
ADHD meds – Consider DATER before changing medication to 2nd/3rd line
Dosage
All - trial of all 1st line
Time - enough time given for response/side effects to resolve
Examine - what are the targets? what standardized measures
Review - comorbidity, lifestyle
ADHD non rx management
patient and family education
psychological treatment
education accommodations
driving – restrict cell phone use, recommend manual transmission
ODD vs conduct disorder
ODD children do not show aggressions towards peope/animals; destroy property; pattern of theft and deceit
Bedwetting management
make toilet accessible pee before bed including in morning cleanup training pants avoid fluids/caffeine/chocolate before bed do not punish, introduced diapers enuresis alarms desmopressin for short-term
Well baby care counselling safety
No honey Choking hazards Vitamin D Breast/fed is best button battery ingestion No guns Carbon monoxide detector Cover electric plugs Hot water heater car seats Storage and poison control
Milestones
2 months - two = coo, smiles 4 months - hold object - four fingers and hold head, laughs 6 - sit at six with support 8 - pincer grasp 1 year - walk, 1 word; responds to name 15 months- stranger danger 2 - run, 2 word sentence, 1-2 step directions 3 - 3 step instructions 5 - adult like sentences
Breastfeeding guideline
> =2 years
400IU daily vitamin D
circumcision, pros and cons
pros
- decreased infection - phimosis (rx with topical steroids), uti, hpv, cancer
cons
- pain, stenosis, damage to surrounding tissues
undescended testes sequelae
torsion trauma tumor inguinal hernia infertility
torsion TWIST score
absent cremasteric reflex nausea/vomiting testicle swelling testicle hard high riding testicle
When to refer for testicles in children
refer if
- not descended at 6 months
- not there anymore
- not there
- not positioned properly
AIDS defining illnesses
Kaposi’s sarcoma Pneumocystis jirovecii pneumonia (PCP) Cytomegalovirus Candidiasis (oesophageal or bronchial) Lymphomas (excluding Hodgkins) Tuberculosis
when to give Tdap to pregnant ladies
> 13, ideally 27-32 weeks
which vaccines can you NOT give if someone is breastfeeding?
BCG, yellow fever, japanese encephalitis
Under what circumstances do we have to delay vaccines if someone is ill?
lots of congestion – don’t give nasal flu
acute GI – defer cholera, dukoral
mod to severe – defer rotavirus
who gets flu vaccine?
kids > 6 months
everyone, but esp adults with neurologic/developmental conditions, work in health care, work with poultry
> 65 yo
vaccines in person with egg allergy
flu, MMR ok
do not give yellow fever, tick-borne encephalitis or rabies
make vaccine less painful?
breastfeed skin to skin most painful last sugar tylenol after, otherwise blunts immune response topical anesthetic don't aspirate
what are the two shingles vaccines?
what kind, how often, how $$$, how effective?
zostavax = live attenuated
1 dose, $170, >60 yo
shingrix = non live recombivant, adjuvanted
2 doses, 2(-6) months apart
2x as effective, 2x as much
>50yo
HPV vaccine - # of doses, #-valent
2 doses, 9-valent, all genders
who do you give meningitis C to? (5)
all travellers to Hajj meningitis belt of africa military recruits asplenia and sickle cell all canada adolescents
vaccine cautions for the immunocompromised? keep 3 things in mind
- no polio, varicella, MMR
- close contacts: avoid giving or avoid contact for 2 weeks
- consult public health/ID
vaccines contra-indicated in…
pregnancy? TB? severe asthma/medical wheeze in last 7 days? uncorrected GI malformation? HIV?
pregnancy: live vaccines (polio, varicella, MMR), BCG –> flu ok
active TB: MMR, varicella, herpes zoster, BCG
asthma: live attenuated influenza
GI malformation: rotavirus (risk of intussception)
HIV: all live vaccines
Common cold treatment? (5)
NSAIDs, honey (> 1 year), intranasal ipratropium, nasal decongestant/anti-histamine (>5 year), zinc (not intranasal)
sinusitis risk factors? (4) which bugs?
allergic rhinitis asthma anatomy smoking ear bugs
Sinusitis complications and red flags? (9)
Osteomyelitis, intracranial abscess, epidural abscess, meningitis, periorbital/orbital cellulitis. fever > 39 periorbital edema cranial nerve palsies abnormal EOM proptosis vision changes severe headache altered mental status meningeal signs
what are the meningeal tests?
Brudzinski - flexed neck –> flexed extremities
Kernig - with hips flexed cannot extend knee
PODS acute sinusitis
pressure/pain obstruction (nasal) dischage - thick, purulent smell, loss of 2 or more -- persists for >7-10 days
mgmt of acute sinusitis
ct/xr only if red flags amox 500 TID 5-10 days nasal steroids! nasal rinse decongestants analgesics anti-inflammatories mucolytics
why give abx for GAS? what does it NOT prevent?
prevent... AOM rheumatic heart disease sinusitis decrease illness <1 day peritonsillar abscess does NOT prevent glomerulonephritis
mono - how does it spread? symptoms? labs? recommendations re: spleen?
saliva
lymphadenopathy, fatigue, sore throat, splenomegaly, headache
lymphocyte count, serume AST/ALT, monospot
NO abx
no contact sports min. 3 weeks, can last up to 8 weeks
Jaundice beyond two weeks, order:
hemoglobin serum conjugated bili coomb's test group and screen peripheral smear
Symptoms of down syndrome - rule of 1s
1st toe web space
1 palmar crease
1% recurrence
Hip dysplasia risks, ffff
first born feet -- breech family history fluid -- oligo female
full septic workup in kids
CBC
LP
CXR
urine/blood cx
pediatric LIMPSS cannot miss
Legg calves perthe Infectious Malignancy - ewing's sarcoma, osteosarcoma Pain from a fracture - abuse? Slipped capital femoral epiphysis Something else above/below
Classes and examples of constipation meds
Stool softeners – docusate (colace)
Osmotic laxatives – lactulose, Mg salts, sorbitol, PEG
Bowel stimulants (motility agents) – senna, bisacodyl, cascara, prune juice
Bulking agents – psyllium, bran (Metamucil ok)
Bowel lubricants – mineral oil, castor oil, glycerine
Enemas – tap water, saline, sodium phosphate (fleet), oil
Counselling pts for HCV - 4
Discussion of avoidance of alcohol
Monitoring of progression (ALT/AST, annual AFP)
Counsel on risk of transmission
Screening sexual partners
HCV treatments
Pegylated Interferon Ribavirin Telaprevir Simeprevir Sofosbrevir Harvoni (ledipasvir/sofosbuvir) Holkira Pak (dasabuvir, ombitasvir, paritaprevir, ritonavir) velpatasvir daclatasvir
Mechanism of scaphoid #
Extreme dorsiflexion of the wrist with compressive force to the radial side of the palm
Fall on outstretched hand/arm
Forceful radial deviation and dorsiflexion of wrist
Direct axial compression or hyperextension of the wrist
Physical exam for scaphoid fracture
Anatomic snuffbox tenderness
Scaphoid tubercle tenderness (extend the patient’s wrist with one hand and apply pressure to the tuberosity at the proximal wrist crease with the opposite hand)
Positive results on the scaphoid compression test (axially/longitudinally compressing a patient’s thumb along the line of the first metacarpal)
Swelling on the dorsoradial side of wrist or over the anatomical snuffbox
Pain in the snuffbox with pronation of the wrist followed by ulnar deviation
Reproduction of pain when patient pinches tips of their thumb and index finger together
Scapholunate disruption on xray
A gap of more than 3 mm between the scaphoid and lunate bones (the Terry Thomas sign)
Scaphoid #, reasons to refer to ortho
open fractures neurovascular compromise displacement of 1 mm or more angulated fractures associated tilt of the lunate bone associated carpal instability evidence of nonunion or displacement during follow up osteonecrosis possible scapholunate dissociation proximal pole fractures oblique fractures unwillingness or inability of the patient to wear a cast for up to 3 months
Why does scaphoid have higher rates of fracture complications?
The scaphoid bone has a tenuous blood supply running from distal to proximal.
RATIONALE: The blood supply comes from the radial artery, feeding the bone on the dorsal surface near the tubercle and scaphoid waist with no direct blood supply to the proximal portion. Thus, there is an increased possibility of nonunion or osteonecrosis with fractures, particularly those of the proximal pole.
Symptoms of hypercalcemia
mental status change confusion poor concentration abdominal groans (e.g. abdominal pain) nausea vomiting anorexia fatigue/lethargy renal colic dehydration polyuria polydipsia constipation bone pain muscle weakness anxiety depression
Rx for hypercalcemia
Hydration with normal saline
Calcitonin
Bisphosphonates
Medications that cause hypercalcemia
ationale: Thiazide diuretics (class or specific drug name of any thiazide acceptable) Lithium Teriparatide Abaloparatide Theophylline Excessive vitamin A Excessive vitamin D
1st blood test to order with dx of hypercalcemia
PTH
Risk factors for neonatal jaundice
Prematurity
Vacuum delivery leading to cephalohematoma
Asian background
Possible dehydration (poor weight gain)
Blood tests in neonatal jaundice
Blood type (ABO and Rh status) of infant Direct antiglobulin test (direct Coomb’s test)
Inherited disorders that cause hyperbilirubinemia in infants
Glucose-6-Phosphate Dehydrogenase Deficiency
Pyruvate Kinase deficiency
Crigler-Najjar syndrome
Hereditary spherocytosis or elliptocytosis
Hemoglobinopathies (sickle cell, thalassemia, Hemoglobin H disease)
Side effects from phototherapy?
Dehydration
Bronze baby syndrome / bronze discolouration of the skin
skin rash
over or under heating of infant / temperature instability
loose stools/diarrhea
electrolyte disturbance (hyponatremia or hypokalemia)
interference with maternal –infant interactions
Ocular damage
Causes of hyperbilirubinemia in babies <24 hrs
hemolytic disease of the newborn (Rh or ABO incompatibility, spherocytosis, G-6PD deficiency, Kell Congential hemolytic states)
Maternal autoimmune hemolytic anemia (e.g. lupus) Type 1 – usually by day 3
Concealed hemorrhage/hematoma
Vitamin K deficiency
Treatment for ABRS
amox, nasal steroids
Classic sites for infantile eczema
Cheeks
Face
Scalp
Extensor surfaces (elbows and knees would count as 2 answers)
1/2 point for Flexor surfaces (flexor surfaces can be found in any age, however, extensor surface involvement is more classic for infantile eczema)
Trunk
Risk factors for infantile eczema
Positive family history of atopy (give ½ point for either “allergy” or “asthma”) Weather changes (cold, dry) Chemical irritants (scented soaps, detergents)
strategies to prevent/treat eczema
Reducing frequency of baths Unscented products (soap, detergents) Minimize soaps Emollients Barrier creams Use luke warm water for baths Avoiding triggers or irritants Exclusive breastfeeding (although some small studies are refuting this) Parental education Topical steroids Antibiotics in severe cases
when to treat asymptomatic BV?
Pregnant women with history of a high-risk pregnancy (previous preterm delivery)
Prior to IUD insertion
Second trimester even if asymptomatic (check this)
Prior to gynecologic surgery/therapeutic abortion/genitourinary instrumentation
Immunocompromised patient
abx to treat trich? what else can be used for BV?
metronidazole
clinda, doxy
Pediatric Limps LIMPSS
Leg Calve Perthes Syndrome - boys, age 4-10, white Infection/inflammation Malignancy - Ewing's Sarcoma (small round blue cells - pelvis, thigh, lower leg, upper arm, and rib), Osteosarcoma (Osteosarcoma usually develops at the edges of the long bones, in the “metaphysis” esp. the knee) Pain from a fracture - abuse? Slipped Capital Femoral Epiphysis - obese, adolescent, black/latino Something above or below?
HEADSS
Home environment - smokers, smoke alarms Education - bullying Activities - helmets Drugs - prescription drugs Sexuality/sex Suicide
Kawasaki’s CRASH
Conjunctivitis Rash Adenopathy Strawberry tongue Hands and feet swollen/rash/peeling if you CRASH call the CAA --> coronary artery aneurysm treat with ASA and IVIG kawASAkI
Violent/aggressive patient? Think of other causes
DIM FACES
Drugs/dehydration
Infection
Metabolic/medication change
Failure Anemia/alcohol Cardiac/stroke/bleed Electrolytes Structural/seizure disorder/psychiatric
Which vaccines should you consider for travel?
General - Hep A and B, rabies
Country specific - typhoid, meningitis, yellow fever, encephalitis
routine - flu, shingrix, pneumococcal, tetanus, pertussis
Anti malarial medications and their pros/cons?
Malarone - only for 7 days after exposure daily, expensive
Doxy - cheap but photosensitivity rash. daily dose, need for 30 days after exposure
Mefloquine - frequent side effects, vivid dreams. once weekly
primaquine - only for 7 days after exposure; daily dose need test for G6Pd
chloroquine - cheap, safe, widespread resistance so check first, skin and corneal side effects
Rx for traveller’s diarrhea and how to prevent
Azithro oral rehydration solution loperamide bismuth subsalicylate boil, peel; avoid ice cubes, salads, uncooked veggies use bottle water, wash hands often
medications for altitude sickness?
acetazolamide - carbonic anhydrase inhibitor dexamethasone nifedipine sildenafil/tadalafil prophylactic salmeterol
AAA screening
men 65-80 one time ultrasound
calculate sensitivity
specificity
ppv
npv
sens = true pos / true pos + fals neg spec = true neg / true neg + fals pos ppv = true pos / true pos + false pos npv = true neg / false neg + true neg
DM screening
- Screen every 1-5 y depending on risk
determined using a calculator, other risk
factors, or age ≥40 y - HbA1c level is the preferred screening test
(FPG level or OGTT are acceptable
alternatives) - HbA1c level of ≥6.5%, FPG level of
≥7 mmol/L, or 2-h plasma glucose level
in an OGTT of ≥11.1 mmol/L are diagnostic
DLP screening
- Screen fasting lipid profile in men aged ≥40 y,
women aged ≥50 y (or postmenopausal), or
earlier if at increased risk - Screen with Framingham risk assessment
every 3-5 y if 10-y risk is <5%, or every y
if 10-y risk is ≥5%, until age 75 y - Framingham risk should be doubled if
positive family history for premature
cardiovascular disease - Discuss “cardiovascular age”
Colon Ca screening
- Screen with FIT or FOBT every 1-2 y, or
flexible sigmoidoscopy every 10 y, if aged
50-75 y - Consider individualized opportunistic
screening with FIT or FOBT, flexible
sigmoidoscopy, or colonoscopy up to age
85 y
HPV recommendations
1. Recommended for women up to age 45 y even if already sexually active and regardless of past infection 2. Recommended for men up to age 26 y 3. Recommended for men who have sex with men
Immigrant health, four areas - infection
HIV, Hep C, TB
mantoux skin test is intradermal
TB rx, RIPE
Rifampin
Isoniazid
Pyrazinamide
Ethambutol
Common parasitic infections? Ss
strongyloides
Schistosomiasis
Unconscious patient? DONT
dextrose
oxygen
Narcan
Thiamine
Rx for new psychosis?
start med 1st gen = 2nd gen maintain for 18 months oral = depo if depression, treat that too.
neuroleptic malignant syndrome FARM and treatment (5) and meds (3)
Fever
Autonomic - BP, HR, sweating
Rigidity
Mental status changes
stop the rx; IV NS; cooling blankets; ice packs; DVT prophylaxis
benzos if agitation; bromocriptine; dantrolene for muscle relaxation
qSOFA
resp rate >22
aMS
SBP < 100
STI abx
cefixime + azithro or doxy OR
ceftriaxone + doxy if PID
sinusitis abx
amox or amox-clav
bronchitis abx
none
diverticulitis abx
none if CT confirmed with no abscess/free air
cipro + flagyl or amox clav
sepsis abx
ceftriaxone or pip tazo +/- vanco
yeast vaginitis rx
fluconazole oral
pneumonia abx
macrolide or fluoroquinolone
meningitis abx
< 1mo - amp + gent
Group B Streptococci
E. coli
Listeria spp
1-3 mo amp + cefotaxime Group B Streptococci E. coli Listeria spp S. pneumoniae N. meningitidis H. influenzae
> 3 months cef + vanco S. pneumoniae N. meningitidis H. influenzae
Adult > 50 years or Immunocompromised (including AIDS), Alcohol abuse, Debilitating illness, Pregnancy cef + amp + vanco S. pneumoniae Listeria monocytogenes N. meningitidis Enterobacterales
cellulitis abx? MRSA?
with pus = ?mrsa = doxy, septra, clinda
w/o = strep = amox clav, cephalexin
uti abx
nitrofurantoin, septra, cephalexin, fosfomycin
pyelo abx
ceftriaxone
then cefixime or septra or cipro or amox-clav
remember your TOCC hx
travel
occupation
contacts
critters
4 strategies to minimize statin effects on muscles
lower dose
rink lots of fluids
stop interacting medications
alternative day dosing
rx for molluscum contagiosum
cantharidin topical
Describe arterial ulcer
Punched out full thickness ulcer with smooth wound edges often on lateral ankle or distal digits
Describe karposi sarcoma
Red-purple lesions/patches/nodules
Describe scabies
intensely pruritic and pimple like rash at the wrists and Intertriginous areas
describe herpes labialis
small grouped blisters/sores on lips that can coalesce into an ulcer that heals with 2-3 weeks
describe hand foot and mouth
lesions on oral mucosa, tongue, palms, soles and buttocks, grey-white vesiculo pustules
describe venous ulcers
shallow and superficial ulcers with irregular margins usually on the lower leg and ankle
rf: obesity, immobility, pregnancy, DVT, CHF, varicose veins, conditions with poor musculature
describe herpes zoster
grouped, unilateral vessicles in dermatomal distribution +/- pain and prodromal symptoms. anti virals with in 48-72 hours
–> do not confuse with eczema herpeticum
indications for shingrix vaccine
over 50 years, diabetes, heart disease, renal disease, immunosuppresion
describe BCC
shiny, pearly nodule located on sun exposed area of skin with telangectasia
rx: excision, cryotherapy, topical chemo
describe roseola infantum
high fever then rash on chest that turns into a pink maculopapular eruption lasting 1-2 days. 6th disease, HHV 6/7, supportive care
describe erythema infectiosum
macular erythema on face on day 1, then erythematous maculopapular eruption for up to 7 days on proximal extremities, then a reticulated or lacy erythema on extensor extremities up to 3 weeks. parvovirus/5th disease
Dx of HTN, work-up
AOBP > 135/85 or non-AOBP >140/90
Lipid panel (HDL, LDL, chol, trig, non-HDL)
Na, K, Creat, urinalysis, HbA1C, EKG
CPAP does not decrease morbidity/mortaliity
Recommendations for HTN lifestyle
reduce salt - diet - DASH <1800mg reduce weight reduce stress - CBT increase exercise 30-45 min, 3x/week reduce alcohol <2.7 drinks/day
Fever? keep the ddx broad (11) and don’t forget the most dangerous things
sepsis meningitis steven's johnston syndrome PE GCA medication cancer/feb neut serotonin syndrome neurleptic malignant syndrome endocarditis rheum -- still's disease unclear? back to basics, serial exams/ekgs/imaging
DLP screening. When should it be fasting?
> 40 and <75 consider earlier in at risk groups: South/East asians and First Nations, gestational HTN
Fasting if TG > 4.5
no evidence of mortality benefit of statins if >75
DLP management
Statin based on Framingham > 10 OR if CHD, CAD, PAD, AAA, DM2, CKD
Optimize renal, HTN, and CVD rx
dietician (med diet), counselling, stop smoking, kinesiology, cardiology, endocrinology (if familial)
Vertigo Exam (4)
Orthostatic BP
Gait
Hints
Dix-Hallpike
Vertigo ddx
BPPV orthostatic meniere's migraine neuritis stroke
HINTS exam
Pt looks at nose; head impulse to one size
continues looking at you = normal (central vertigo)
corrective saccades = abnormal (peripheral vertigo)
Acute situatuation - ABC MOVIES and cereal
monitors oxygen vitals IV large bore x 2 ECG sugars serial ekgABCs/vitals
GI Bleed rx
PPI infusion
Erythromycin prior to scope because it increases GI motility
Hgb only if <70
IF varices, give ceftriazone and somatostatin (octeotride)
what’s the reversal agent for…
warfarin?
heparin?
dabigatran?
vit K
protamine, fresh frozen plasma
praxbind
what are the drug classes for anxiety?
benzodiazepines buspirone selective serotonin reuptake inhibitors selective norepinephrine reuptake inhibitors tricyclic antidepressants monoamine oxidase inhibitor atypical anti-psychotics
after SIGECAPS, r/o other conditions by asking about
- excessive worry, panic, PTSD
- hallucinations?
- rituals/compulsions that you cannot stop?
- mania – feel better than good?
- delusions - do you have special powers? is there a plot against you?
Bipolar II, criteria and dx
Bipolar meds
- hypomania, no psychosis
quetiapine is first line
Acute: abilify, paliperiodone, risperidone
Maintenance: quetiapine, lamotrigine, lithium, divalproe
1st gen antipsychotics - D2 antagonism, higher risk of neurological side effects
haldol
chlorpromazine
2nd gen antipsychotics “atypicals” 5HT2A/D2 antagonism
higher risk of metabolic side effects
abilify olanzapine paliperidone quetiapine risperidone clozapine
Tourette syndrome rx
Tetrabenazine or Risperidone (dopamine blockers)
Botox - neuromuscular blocade
Habit reversal training
PICA rx
methylphenidate - CNS stimulant
olanzapine
Treat the complications – radiography for a bezoar
Scabies rx
permethrin, invermectin
Mastitis rx
continue BF
NSAIDs, abx
usually staph
warm/cold compresses
Melanoma dx
Asymmetry Border irregularity Color not uniform Diameter > 6mm Evolving shape/size/colour
Measles description, symptoms
purplish red, maculopapular rash starting on the scalp/face/neck and spreading downwards
Four Cs: cough, coryza, photophobia, conjunctivitis, koplik spots on buccal mucosa
Alopecia areata
circular lesion on scalp/body with no hair, may have characteristic exclamation mark hairs. Focal, non scarring
ddx: trichotillomania
associated with SLE, thyroid, family hx
Marjolin ulcer
non healing ulcer or growth on the edge of a hronic wound - type of SCC
Pityrasis rosea
single lesion followed by all over body rash. Oval, dull pink colour involving the trunk and upper arms and legs. Christmas tree distribution
Head lice rx
permethrin or pyrethrin, repeat in 7-10 days
Rx for alopecia
stop offending meds
minoxidil
finasteride
hair transplant
Rosacea
superficial, dilated blood vessels and papules/pustules/swelling on the face
stevens-johnson syndrome
painful red or purplish rash involving the skin and mucous membranes stop med/avoid drug class in future
Koebner’s phenomenon
formation of psoriasis in areas of trauma
Rx for post herpetic neuralgia
topical capsaicin NSAIDs gabapentin TCAs glucocorticoids paracetamol topical lidocaine
investigations to order for dx osteoporsis
hgb TSH ionized Ca Alk Phos Creatinine SPEP if vertebral # Vit D --> after 3 months of Vit D supplementation
Osteoporosis rx - 3 options + 2 for high risk
When can you stop it?
Bisphosphonates
- jaw osteonecrosis
- esophageal ulcers
- atypical fractures
Raloxifene –> selective estrogen receptor modulator
- VTE/PE
HRT
for high risk
Teriparatide - PTH analogy
- hypercalciuria, hypercalcemia - usually transient
- angioedema
Denosumab - monoclonal ab vs. RANKL
- joint muscle pain
- jaw osteo
- CI in pregnancy
Stop after 3-5 years if low risk take holiday
HIV med complications
DLP
hyperglycemia
BMD loss
Renal disease
HIV meds to know
Truvada for PREP
Zidovudine - peripartum and neonate
PEP - truvada, raltegravir
Opioid guidelines
maxmimum 50mg MED start
taper down to 90mg MED if they are above that
only use if no other options - TCAs, nabilone, NSAIDs, CBT, exercise, physio
ADL - DEATH
Dressing Eating Ambulating Toileting Hygiene
IADLS - SHAFT
Shopping Housework Accounting Food and meds Telephone, transportation
Frail elderly checklist
vision hearing skin - ulcers mobility cognition pain medications rx monitoring abuse driving incontinence falls teeth
Post phlebitic syndrom
horse chestnut seed extract for venoconstriction
DVT w/up and treatment
if low Pre test prob/Wells < 2 – D-dimer. if +ve, proximal leg compression ultrasound or CTPA if you suspect PE
if high Pre test prob/Wells >2 – ultrasound. if -ve, d dimer
if suspicion is high and testing will be delayed, treat first!
1 dose of oral Xa inhibitor or 1 dose of LMWH/IV heparin
Bell’s palsy, dx and treatment
Stroke spares forehead
lubricant eye drops
steroids eg prednisone
add antivirals if severe
Ramsay Hunt Triad
aka Herpes Zoster reactivation
- ipsilateral facial paralysis
- ear pain
- vesicles in the auditory canal
Ischemic vs hemorrhagic findings
ischemic 80% - early, focal
Hemorrhagic 20% - late focal deficits, compression effects (headache, vomiting)
Acute stroke management
- ABCs, MOVIEs
- Stroke scale
- Labs: Na, K, Hgb, INR, aPTT, creatinine, troponin, glucose
- Head CT non contrast –> if 4.5-6 hours adter symptoms add CT angiogram from vertex to arch OR CT perfusion. If 6-24 hours after symptoms add CT angiogram AND CT perfusion
- Treat fever and severe hypertension >220/120
Acute stroke treatment options
- Bust clot - alteplase, tenecteplase
- treatment within 3-4.5 hours, >18 yo - Yank clot 6-24 hrs- endovascular thrombectomy, aspiration/vacuum/removal stent
- acute ischemic stroke, anterior circulation, large vessel
Stroke w/up (cause - 4)
- Holter monitor
- Carotid doppler/duplex ultrasound
- manage A fib if found
- ECHO
Stroke prevention ABCDEs
A Fib BP CVD DM2 Ethanol
cephalosporins
1st gen - cephalexin (keflex) PO, cefazolin (ancef) IM/IV
2nd gen - cefuroxime IM/IV
3rd gen - cefixime PO, ceftriaxone IV
no activity against LAME = listeria, atypicals, MRSA, enterococci
Good against gram +ves, increasing gram -ves as you progress at expense of gram +
Macule
flat lesion less than 1 cm, without elevation or depression
Patch
flat lesion greater than 1 cm, without elevation or depression
Plaque
flat, elevated lesion, usually greater than 1 cm
Papule
elevated, solid lesion less than 1 cm
Nodule
elevated, solid lesion greater than 1 cm
Vesicle
elevated, fluid-filled lesion, usually less than 1 cm
Pustule
elevated, pus-filled lesion, usually less than 1 cm
3 indications for using cannabinoids ? which product for which indications?
Muscle spasm 2/2 SCI, MS - nabiximol
Neuropathic pain refractory to standard therapies- nabilone or nabiximol
N/V from chemo - nabilone
4-6-8 rule for driving after cannabinoid
don’t drive less than 4 hours
less than 6 hours for oral ingestions
and less than 8 if you experience euphoria
managing opioid withdrawal
treat type of pain - neuropathic vs other
clonidine if BP >150/90, HR >50; for nausea/vomiting/sweating/tremor
diarrhea - start loperamide, stop stool softeners
abdo cramping - buscopan (hyoscine), pinaverium
muscle cramping - quinine
sweating - oxybutynin (anti-cholinergic)
what are the domains for major neurocognitive disorder? 5 W’s
WHO you are, WHAT you say, WHERE you go, WHY you do things, WHEN you remember
learning and memory complex attention executive function language, perceptual motor social cognition Alzheimer's is any one PLUS memory affected mild = 1 domain major = 2 or more plus impair function/decline
how to assess competency?
explain your treatment options? WHAT
reasoning? WHY
choice? WHAT ELSE
investigations for MNCI d/o?
TSH Hgb/ferritin B12 Na, Ca, glucose
if less than 2 years ago/looking for something else
Management for MNCI
- cholinesterase inhibitors –> donepezil
- glutamatergic –> memantine
exercise
cognitive stimulation
avoid antipsychotics
Parkinson’s symptoms TRAP SSSS
Tremor Rigidity Akinesia Postural instability Shaky Stiff Slow Steps
DDx for Parkinson’s
Essential - improves with EtOH?
Antipsychotic? - extrapyrimidal side effects
Parkinson’s - at rest?
falls, slow vertical gaze - progressive supranuclear palsy
no L-dopa improvement, symmetric - MSA
Parkinson treatment, things to avoid (5), treat other features
first line - carbidopa/levidopa
30% don’t respond, 20% who do have another dx
second line -
1. Dopamine agonists, non ergot - pramipexole, warn about impulse control d/o i.e. gambling, binge eating
avoid ergot derived i.e. bromocriptine
- MAO inhibitors - selegiline, rasagiline
Avoid… anti psychotics (except quetiapine, clozapine); abruptly stopping meds; amantadine early on; genetic testing/PET scanning; vit E/coenzyme q10
constipation, drooling, ED, hypotension
Rx for postural hypotension
quit - large meals, EtOH, warmth, medications
start - compression stockings, increase salt intake, bed tilt, elastic stockings, midodrine (alpha 1 agonist) or corticosteroid
headache – serious causes to r/o
GCA SAH Stroke meningitis Tumour
red flags for headache SNOOP
systemic features neuro symptoms older pt/onset other red flags pattern change
ottawa SAH tool
r/o tool for 4 criteria, C/I (5),
alert patients >15 years old new severe atraumatic headache maximum intensity in 1 hr do NOT USE if: neuro deficits, prior aneurysm, prior SAH, known brain tumour, chronic recurrent headache require investigations if: 1. neck pain or stiffness 2. => 40 yo 3. witnessed LOC 4. peak during exertion 5. thunderclap headache -- immediate peak intensity 6. limited neck flexion on exam
Migraine Rx - acute, chronic, lifestyle management
Migraine medications: A) Acute migraine medications. B) Prophylactic migraine medications.
A)
Type ACUTE MEdications
First line Ibuprofen 400 mg, ASA 1000 mg, naproxen sodium 500-550 mg, acetaminophen 1000 mg
Second line Triptans (oral wafer/nasal spray/IM)
Antiemetics: domperidone 10 mg or metoclopramide 10 mg for nausea
Third line Naproxen sodium 500-550 mg in combination with a triptan
Fourth line Fixed-dose combination analgesics (with codeine if necessary; not recommended for routine use)
also consider – sphenopalatine ganglion block
B)
Prophylactic Medications
First line
• propranolol/metoprolol - avoid in asthma
• ami/nottriptyline - Consider if patient has depression,
anxiety, insomnia, or tension-type
headache
Second line • topiramate • candesartan • gabapentin Few drug interactions Botox for chronic
Lifestyle management:
- decrease caffeine, improve sleep, increase exercise, relaxation, CBT
ABCDs of fractures
Antibiotics? Analgesia Brace/splint Consult ortho? Compartment syndrome? Stick them with Tetanus -- Tetanus immunoglobulin if dirty wound/not vaccinated or immunocompromised
Fractures of abuse (8)
multiple multiple, many healing non ambulatory femur <12-18 months humerus <18 months skull metaphyseal - bucket handle rib posterior
Salter-Harris
Slipped Type I Above Type II Lower Type III Through or transverse Type IV Rammed Type V
causes of Afib (6)
ischemic valvular alcohol hyperthyroid HTN pulmonary - COPD, pulmonary embolism
Afib rx, anticoagulate?
convert IF unstable, symptomatic/poor QOL, cardiomyopathy
otherwise bblockers or ccb
if unstable/low clot risk – anticoagulate now and cardiovert now
if hi clot risk, OAC for 3 weeks or TEE
rate control if old, longstanding, asymptomatic, other disease
rhythm control if young, new dx, symptomatic, no other disease
CHADS2
CHF HTN Age >65 DM2 Stroke/TIA/embolism
Bleed risk management HAS BLED
HTN SBP>160
Abnormal liver/kidney fxn
Stroke
Bleeding
Labile INR
Elderly >65
Drugs/EtOH
Which anticoagulant for – CKD? pregnancy? cancer? valvular afib?
UFH - renal disease CKD
LMWH - pregnant, cancer
Warfarin.- valvular
Systemic Exertional Intolerance
Functional impairment > 6 months Non exertional new fatigue Post exertion malaise Rest does not refresh At least 1 of cognitive impairment or orthostatic intolerance
Panic attack symptoms
Students Fear CCCs Sweating Trembling Unsteadiness Dyspnea Excessive sweating Nervousness Tachycardia/tachypnea Sensation weird Fear of death Choking Chills Chest pain
Lupus
MD SOAP BRAIN
Mallar rash
Discoid Rash
Serositis - pericarditis, pleuritis
Oral ulcers
ANA +ve
Photosensitivity
Blood - thrombocytopenia, hemolytic anemia
Renal - GN
Arthritis
Immune - anti phospholipid, anti dsDNA, anti rho, C3/C4, anti smith
Neurological disorders, including psychiatric disorders - psychosis, seizures
Thyroid Storm
Altered mental status Tachy Fever Dyspnea/orthopnea Chest pain Hypertension Profuse sweating
IBD systemic features APIESAC
Apthous ulcers Primary sclerosis cholangitis, pyoderma gangrenous Iritis/uveitis Erythema nodosum Sacroilitis Arthritis Clubbing
Pro-thrombotic states
Protein c and s deficiency - like renal disease because you lose protein Nephrotic syndrome Hormonal meds Pregnancy Cancer IBD, CHF Factor V leiden Anti phospholipid syndrome
Upper Arm DVT
CONSTANS score — upper arm DVT
1 point each, -1 if other dx more likely
Unilateral pain
Edema
Hx of central line/pacemaker placement “trauma”
Risk factors for AOM
maternal smoking
pacifiers
day care
bottle feeding
Ear bugs? 5
strep pneumo moraxella catarrhalis hemophilus influenza staph aureus group a strep
rx for AOM? if failure?
amoxicillin - high is BID, low if TID 40-90mg/kg
if failure? clavulin or ceftriaxone
tylenol 10mg/kg
advil 15 mg/kg
what are the indications for ear ventilation tubes?
>6/yr or 4 per 6 months or Chronic OM with effusion, "glue ear" > 3 months with hearing loss or retracted TM
CATCH2 for pediatric head injury, AVPU?
Minor head injury and any one of the following
GCS <15; Awake - Verbal - Responds to Pain - Unresponsive
worsening headache
Suspected open/depressed skull fracture
irritability
Sign of basal skull fracture
Large, boggy scalp hematoma
Dangerous mechanism
>4 episodes of vomiting (common pain response in kiddos)
types of SHOCK
septic hypovolemic obstructive cardiac AnaphylacticK
Burns - formulas? special sites?
> 10% resuscitate - Brooke formula: 2mls x body surface areas burned (BSAB) x weight
Rule of 9s
adult - legs 18% x 2, arms 9% x 2, head 9%, chest 18%/back 18%, groin 1%
infant - legs 14% x 2, arms 9% x 2, head 18%, chest 18%/back 18%, groin 1%
special sites: face, hand, foot, genital, perineum, joint
Frostbite rx - 5 steps
rapid rewarming - water bath possible thombolysis and heparin and iloprost sterile wound care consult surgery tetanus
MAPLE hx
medications allergies past medical history last meal events leading up to
GCS
4 - eye response; 4 spontaneous - 3 sound - 2 pressure
5 - verbal; 5 oriented - 4 confused - 3 words - 2 sounds
6 - motor; 6 obeys - 5 localizes pain - 4 withdraws from pain 3 - flexion to pain 2 - extension to pain 1 - no movement
ATLS updates
give blood early! after 1L crystalloids
smaller chest tubes 28-32 french
needle decompression 4th/5th intercostal space laterally
use massive transfusion protocols
tranexamic acid 1g for 10 min and 1g for 8 hours
e-fast for pneumothorax
Trauma in pregnancy
Mom then fetus Chest tube 1-2 spaces higher NG tube Left lateral decubitus No vag exam until previa ruled out Anti D immune globulin if Rh negative Tetanus vaccine is safe Document domestic violence
