common problems Flashcards
Workup of patient w/new onset migraines?
-BMP, CBC, -VDRL (r/o syphilis) -ESR -*CT head
Clinical presentation of basal cell carcinoma
waxy “pearly” appearance central depression or rolled edge
Second degree burn
** partial thickness -moist, BLISTERS, extends beyond epidermis
Pupil changes seen in narcotic toxicity
MIOSIS **cocaine causes Mydriasis
First degree burn
-dry, red, NO blisters, involves epidermis only
Management of hypercalcemia
Calcitonin (inc Ca reabsorption) if impaired CV or renal fxn *if >12, start NS infusion w/loop diuretics
Treatment of narcotic overdose
-gastric lavage/activated charcoal -Naloxone (narcan) -Butorphanol (stradol)
Tylenol OD equivalent medications?
Anacin-3 Panadol
Actinic keratoses
PREMALIGNANT to squamous cell carcinoma -asymptomatic
Which type of HA is a/w “cold-like” sxs?
cluster HA
which drugs may be causes of non-infectious post op fever?
-ampho B -Bactrim -beta lactam abx -isoniazid -alpha-methyldopa -quinidine
most common organisms causing cellulits- outpatients
strep pyogenes (Gp A strep) -usual cause S.aureus -less common
Treatment for antidepressant toxicity
*admit to ICU if CNS/cardiac toxicity
- gastric lavage/activated charcoal
- sodium bicarb
- Benzos to treat seizures
- Serotonin syndrome: dantrolene
Emergent treatment of Burns
**maintain normothermia (37-37.5)
Use sterile NS as initial tx & wrap burns w/sterile gauze
pain meds Silver Sulfadiazine (silvadene)-antifungal for 2nd &3rd degree burns
When evaluating a HA, what component is most important?
chronology
Clinical manifestations of severe hypokalemia (2.5)
flaccid paralysis tetany hyporeflexia rhabdo
Causes of normal anion gap metabolic acidosis
*diarrhea (CDIFF) -ileostomy -RTA -recovery from DKA
Causes of hypokalemia
-chronic use of diuretics -GI loss -excess renal loss & alkalosis -elevated serum epineprhine in trauma pts
If a patient with hypotonic, hypovolemic hyponatremia is symptomatic, what is the treatment?
NS & Loop diuretic **if CNS sxs–> 3%NS w/loop diuretic
S&S of narcotic toxicity
- drowsiness
- *hypothermia
- resp depression, shallow resp
- coma
First 3 steps in evaluating hyponatremia?
- determine urine Na 2. determine Serum Osmo 3. clinical status
Causes of hyperkalemia
Excess intake -renal failure -drugs (NSAIDS) -hypoaldosteronism -cell death
Drug of choice in treatment of organophosphate poisoning
*Atropine
activated charcoal if ingested
S&S of benzo overdose
drowsiness
confusion
slurred speech
resp depression
hyporeflexia
Causes of Hypocalcemia
hypoparathyroidism
hypomagnesemia
pancreatitis
renal failure
severe trauma
*multiple blood transfusions
Common causes of hypervolemic, hypotonic hyponatremia
-edematous states -CHF -liver dz -advanced renal failure
Limitations of gastric lavage?
limited use for ingestions >30 min use of 28-38F
somatic pain
non-localized, muscle, bones nerves, blood vessels, Soft tissues/Supporting tissues (ex: sprained ankle)
most common organisms causing cellulits- inpatients
-GN organisms: E coli, klebsiella, pseudomonas, enterobacter -S.aureus (MRSA, CA-MRSA)
Dose of narcan
0.04-2mg
Management of cluster HA?
PO drugs usu don’t work
- **inhalation w/100% O2
- Imitrex 6mg SQ may my effective
- Ergotamine tartrate (Ergostat) aerosol INH may be effective
Treatment for hyperkalemia
Exchange resins (I.e Kayexalate) If >6.5: Reg Insulin 10 U IV–> D5W calcium cl or calcium gluconate B2 agonist (albuterol) sodium bicarb
Treatment for salicylate OD?
gastric lavage/activated charcoal sodium Bicarb in severe acidosis (pH <7.1)
*monitor ABGs
What level of albumin indicates protein malnutrition?
<3.5
initial treatment of post op fever?
**hydration and measures to expand lung inflation
Two types of migraines?
class=migraine w/aura common=migraine wo/aura
Management of hypokalemia
>2.5–> PO replacement if unable to take PO–> 10meq/hr
*if <2.5 severe S&S–> can give 40meQ /hr—> check q3hr & continuous ECG monitoring
*ensure Mg WNL
Migraine HA involve which artery and which CN?
d/t excessive pulsations of branches of EXTERNAL CAROTID -CN IV (trigeminal)
When is prophylactic intubation needed in burn patients?
-burns to face -singed nares or eyebrows -dark soot/mucous from nares and/or mouth
3 types of hypotonic hyponatremia?
need to assess if patient is hypovolemic or hypervolemic –> if hypovolemic, need to determine if due to extrarenal salt losses or renal salt wasting hypovolemic hyponatremia w/Na <10 hypovolemic hyponatremia w/Na >20 hypervolemic, hypotonic hyponatremia
Examples of antimetabolites
Azathioprine (Imuran) Mycophenolate mofetil (cellcept)
S&S of salicylate (ASA) OD
N/V
*hyperthermia
*tinnitus
dizziness,
HA
dehydration
metabolic acidosis
inc LFTS
What serum osmo is indicative of hypertonic hyponatremia?
>290
Presence of an aura is only associated with which type of HA?
migraines
Fluid resuscitation management for burn patients
Give 1/2 of all fluid needed in 1st 8hr, w/remaining fluid over the next 16hr
SeBorrheic Keratoses
benign, not painful lesions “stuck on” appearance beige, brown/black in appearance
Cluster HA most commonly affect?
middle aged men
S&S organophosphate poisoning
N/V/D, cramping
*excessive salivation
*HA, *blurred vision
*MIOSIS
*bradycardia
mental confusion, slurred speech, coma
Normal Ionized Ca
1.1-1.4 mmol/L OR 4.5-5.5 mg/dl **ionized Ca NOT bound to albumin, thus doesn’t vary w/albumin level
visceral pain
poorly localized such as w/internal organs
Common causes of hypovolemic, hypotonic hyponatremia w/ Na <10
-dehydration -N -D
Treatment for basal cell carcinoma
shave/pumch bx & surgical excision
Fluid resuscitation calculation in burns
4ml/kg x TBSA
S&S of Herpes Zoster
**pain along dermatomal distribution, usu on trunk *grouped vesicle eruption of erythema & exudate along dermatomal pathway *lymphadenopathy may be present
most common type of HA?
tension
Shortcut to calculate serum osmo?
Na x 2
Corrected Ca calculation
0.8 x (4 - patients albumin) + Serum Ca
what 3 categories of meds are considered standard tx in immunosuppression for transplanted organs?
calcineurin inhibitor antimetabolite steroid
Complications of parenteral nutrition support
-PTX -Hemothorax -**hyperglycemia -**HHNK -arterial lac -air emboli -catheter thrombosis -catheter sepsis
If enteral nutrition is needed for > 6wk, which type of tube should be used?
enterostomal tube (gastrostomy, PEG, J tube)
What Hgb level for W & M can indicate lack of iron or protein resulting in inadequate O2 perfusion?
W <12 M <13.5
Normal osmolality
275-285, **280
Management for acute migraine?
rest in dark, quiet room
simple ASA taken right away may provide some relief
Sumatriptan (Imitrex) 6mg SQ at onset, may repeat in 1 hr (up to 3x/d)
Imitrex 25mg PO at onset of HA
S&S of antidepressant toxicity
confusion, hallucinations,
blurred vision
urinary retention
hypotension, tachycardia, dysrhythmias
hypothermia
*seizures
“can’t see, can’t pee, can’t spit, can’t shit”
Bites to which locations should be left open?
hands & lower extremities *wounds older than 6hrs
S&S of hyperkalemia
-weakness, flaccid paralysis -abd distension -diarrhea
Complications w/enteral nutrition support
- aspiration
- diarrhea
- *hypernatremia
- dehydration
- emesis
- GI bleeding
- mechanical obstruction of tube
Median age at diagnosis of malignant melanoma
40
If parenteral nutrition is needed for < 2weeks, which method should be used?
PPN
Highest mortality of all skin CA
malignant melanoma
Examples of steroids used in immunosuppression
Prednisone Deltasone orasone Meticorten
Which burn patients need to be referred to burn center?
- partial thickness >10% TBSA
- burns that involve face, hands, feet, genitaliza/perineum,
major joints
- 3rd degree burns
- electrical burns, chemical burns
- inhalation injury
- burns + TRAUMA
- *children
Clinical presentation of cluster HA
severe, UNILATERAL, periorbital pain occurring daily for several weeks
- pain occurs at night, awakening pt
- pain usu last <2hr
- pain free mon or wks b/t attacks
- ipsilateral nasal congestion, eye redness, rhinorrhea
ECG findings w/hypokalemia
decreased amplitude broad T waves prominent U waves PVCs–> VT/Vfib
What is the usually the duration of the following types of HA’s? 1. tension 2. migraines 3. cluster
- usu last several hours 2. 2-72hr 3. usu <2hr
S&S of hypokalemia
- muscular weakness, fatigue, muscle cramps
- constipation/ileus
most common skin cancer
basal cell carcinoma
Causes of hypercalcemia
hyperparathyroidism
hyperthyroidism
Vit D intoxication
prolonged immobilization
What serum Osmo is indicative of Hypotonic hyponatremia?
<280
What acid base disturbance and electrolyte derangements should be monitored in burn patients?
metabolic acidosis (expected during early resus) hyperkalemia (early: first 24-48hr)–> hypokalemia (later, ~3d post burn)
Rule of Nines in Calculating Burn Injury 1. Each arm= 2. Each leg= 3. Thorax= 4. Head= 5. Perineum/genitalia
- 9% 2. 18% 3. 18% front & 18% back 4. 9% 5. 1%
Causes of anion gap metabolic acidosis
-DKA -alcoholic KA -LA -drug/chemical anion
Treatment regimens for CA-MRSA cellulitis
Bactrim (95-100%) Doxy/Minocycline (90-95%) Clindamycin (85-95%)
Which drug is recommended as agent of choice for induced emesis in OD?
Ipecac
Common meds for migraine prophylaxis
Amitryptyline (Elavil) Gabapentin (neurontin) Propanolol (inderal) Divalproex (Depakote) Imipramine (Tofranil) Clonidine (Catapres) Verapamil (Calan) Topiramate (Topamax) Methysergide (Sansert)
The type of HA a/w focal neuro disturbances?
migraines
This onset of this type of HA commonly occurs in adolescence and is more common in females than males. A family is history is often present
migraines
Treatment of hypotonic, hypovolemic hyponatremia?
*given NS IV * if Na>20, treat cause
Management of BB overdose
**glucagon atropine as needed stabilize airway
Acidemia _______the ionized Ca level.
Increases
Third degree burn
** full thickness dry, leathery, black, pearly, waxy -extends from epidermis to dermis to underlying tissues, fat, muscle, and/or bone
which type of HA is often generalized, vise-like/tight in quality and is not associated with neuro sxs?
tension
Anion gap calculation
[Na +K] - [HCO3+Cl]
causes of post op fever
-post op atelectasis -increased BMR -dehydration -drugs reactions
Clinical manifestations of malignant melanoma
A: asymmetry B: border irregularity C: color variation D: diameter >6cm E: enlargement
Normal urine Na
10-20
What treatment is indicated for a tar burn injury?
use petroleum based product to remove burning tar -bacitracin -petroleum jelly -mayo
Alkalosis _______the ionized Ca level.
decreases
What are the pupil changes seen in organophosphate toxicity?
MIOSIS (constriction)
Normal anion gap
7-17
What vaccine is needed for dog, cat & human bites?
Rabies
S&S of hypercalcemia
fatiguability muscle weakness depression anxiety N/V constipation **>12=medical emergency (severe hypercalcemia–> coma & death)
When is prophylaxis for migraines indicated?
if attacks occur more than 2-3 times per month
S&S of Beta blocker Overdose
*bronchospasm
hypotension, brady
delirium,
coma
S&S of acute rejection fo a transplanted organ
immediate failure of that organ **flu-like sxs
What is the first step if acute rejection is suspected of a transplanted organ?
BIOPSY
If needing group A strep coverage in treatment of cellulitis, what are possible tx regimens?
add Beta lactam (PCN, Amoxi, or 1st gen cephalosporin-Keflex) to either Bactrim or Doxy
Symptoms of migraines
- UNILATERAL
- dull/throbbing -build up gradually & last for several hours or longer
- focal neuro sxs may precede/accompany migraines
- visual disturbances common
- photophobia/phonophobia
- N/V
Antibiotic prophylaxis for human and animal bites?
PO abx for both staph & anaerobes x 3-7d (e.g Augmentin)
S&S of hypocalcemia
(hyper S&S)
- *prolonged QTc
- inc DTRs
- muscle/abd cramps
- Carpopedal spasm (Troussaus sign) /Chovosteks sign
- convulsions
Normal total Ca
2.2-2.6 mmol/L OR 8.5-10.5mg/dl
Common causes of hypovolemic, hypotonic hyponatremia w/Na >20
(low volume & kidneys can’t conserve Na) -**diuretics -ACEIs -Mineralcorticoid deficiency
Examples of drugs seen in organophosphate (insecticide) poisoning?
Malathion Parathion
At what albumin level would you expect to see edema?
<2.7
Examples of calcineurin inhibitor
Tacrolimus (prograft), cyclosporine
what labs should be monitored in refeeding syndrome?
Phos & K+
What kind of dsg should be put on a decubitus ulcer w/necrotic tissue?
hydrocolloid
What does the leg/foot look like in a hip fracture?
externally rotated
what electrolyte should be monitored in ASA overdose?
K+ (if low, will prevent alkalinzation of urine, which is mainstay of treatment)
what electrolyte should be monitored before administering Succinylcholine?
K+
