Details Flashcards
Mandatory Reporting
Suspected child abuse
Unfit to drive
Reports to workers’ compensation boards
Completion of certificates under vital statistics acts
Diseases (STI, hepatitis, TB, enteric pathogens, foodborne illness, smallpox, anthrax, viral hemorrhagic fevers)
SPIKES Protocol for Breaking Bad News
S - SETTING up the interview
P - Assessing patient’s PERCEPTIONS
I - Obtaining the patient’s INVITATION (i.e., to disclose information)
K - Giving KNOWLEDGE and information to the patient
E - Addressing the patient’s EMOTIONS
S - STRATEGY and SUMMARY
Duty to Warn
- There is a clear risk to an identifiable person or group of persons
- The risk is one of serious bodily harm or death
- The danger is imminent
Psychosis
- an interruption from reality that may affect thought process, thought content, behaviors, and/or perceptions
- manifested by delusions, hallucinations, disorganized thoughts and behaviors, or failed reality testing
Delusions
Fixed, false beliefs that fall outside of cultural norms
Baseline tests for Schizophrenia
- CBC, electrolytes, renal function tests, toxicology screen, liver function tests, thyroid function tests, fasting plasma glucose, lipid panel, and testing for syphilis and HIV
- Consider CT/MRI of head, ECG and chromosomal screening for 22q11
Schizophrenia Treatment
- Atypical antipsychotic first line (less change of EPS and TD but more chance of metabolic syndrome)
- If two fail to control symptoms after 6-8 weeks then switch to clozapine
- Efficacious but has serious side effects (agranulocytosis, seizures, myocarditis)
Olanzapine
- Atypical antipsychotic
- Bad in obesity and diabetics because of risk of metabolic syndromes
Risperidone
- Atypical antipsychotic
- Metabolic complications (weight gain, glucose intolerance, lipid disorders) but less than clozapine/olanzapine
- Galactorrhea, gynecomastia, menstrual disturbance, infertility
Ziprasidone
- Atypical antipsychotic
- Increases QT interval
Clozapine
- Atypical antipsychotic
- Best for refractory (failure to respond to 2 other meds after 6-8 weeks) schizophrenia
- Can cause agranulocytosis, seizures, myocarditis
Quetiapine
- Atypical antipsychotic
- Lower incidence of movement disorders
Aripiprazole
- Atypical antipsychotic
- Increases risk of uncontrolled behavior (gambling)
Amisulpride
- Atypical antipsychotic
Haloperidol
- Typical antipsychotic (high potency)
- Good in pregnancy
- More side effects
- High risk of EPS/TD
Define generalized anxiety disorder? What is the time period?
Excess worry and anxiety about a number of topics for most days for at least 6 months and there are three or more of the following: feeling keyed up, fatigue, concentration problems, irritability, muscle tension, sleep disturbance
AND I C REST
Anxious
No control over worrying
Duration of 6 mo
Irritable
Concentration impairment
Restless
Energy down
Sleep impairment
Tension in muscles
Neuroleptic Malignant Syndrome
- Hypertensive crisis, muscle rigidity, fever, changes in consciousness, and elevated creatine kinase, elevated WCB, metabolic acidosis
- Causes by: antipsychotics, levodopa, lithium, desipramine, phenelzine
- “Serotonin syndrome, it’s a thrill,
with hyperreflexia and shivers that chill.
Neuroleptic malignant syndrome, oh dear,
has rigidity and fever, watch out for sepsis, don’t you fear.
Treatment of Alcohol Withdrawal
- Diazepam 20 mg po q1-2h or 2-5 mg IV/minute (max 10-20 mg q1h) until symptoms subside
- If elderly, severe liver impairment, severe asthma, or resp failure then use lorazepam 1-2 mg PO/SL tid-qid
- Thiamine 100 mg IM initially then 100 mg po qd x 3d
- Antiepileptics if seizure history
- Antipsychotic if hallucinations
- Supportive hydration
Treatment of Opioid Intoxication
- Naloxone 2 mg bolus IV/IM/SL/SC
- Increase by 2 mg increments until symptoms subside (max 10 mg)
- Methadone can be used for detoxification
Health Surveillance in Down’s Syndrome
- At each health maintenance visit: review for celiac symptoms, OSA, cervical spine positioning, myopathy symptoms
- Annually: TSH, hemoglobin, audiological exam, mitral/aortic disease
- Q3Y: Ophthalmological exam for cataracts, refractive errors, corneal thinning, haze
Generalized Anxiety Disorder
Diagnosed when patient finds it difficult to control worry on more days than not for at least 6 months and has 3 or more of the following:
Blank mind
Easily fatigued
Sleep disturbance
Keyed up (restless)
Irritable
Muscle tension
PTSD
- Occurs after life altering/threatening event
- Spontaneous, recurrent, intrusive dreams/memories/flashbacks/reactions
- Symptoms for at least one month occurring anytime after event
Obsessions vs Compulsions
Intrusive, recurrent, undesired thoughts
VS
Repetitive behaviors or rituals
Anxiety Treatment
1st Line: SSRIs (citalopram, paroxetine, sertraline, escitalopram)
SNRIs (venlafaxine, duloxetine)
2nd Line: TCAs, benzo (imipramine or longer acting)
Psychotherapy: CBT
Situational stress vs true anxiety disorder
- Duration and intensity of symptoms
- Stress is a normal response to a challenging situation that typically improves once the situation is resolved
- Anxiety disorder is characterized by persistent symptoms that can last for several months or longer, and may not be directly tied to a specific stressor
AAA screening
• One time screening ultrasound for:
• Men age 65-80
• Women age 65-80 with smoking history or cardiovascular disease
• First degree relatives after age 55
• Repeat ultrasound 10 yr after initial screening if aortic diameter >2.5 cm and <3 cm
Breast Cancer screening
Mammography q2-3y in women 50-74 yo
Cervical Cancer screening
Screen women 25-69 yo q3h
Cease at age 70 if 3 successive negative paps in past 10 years OR continue until 3 successive negatives are obtained
Colon Cancer screening
Screen adults w/o risk 50-74 yo with FIT or FOBT q2y or flex sig q10y
Do not use colonoscopy for screening
At risk (1st degree relative) should start screening at 50 yo or 10y prior to age of relative diagnosis
Fetal Alcohol Syndrome features
Prenatal and postnatal growth deficiency, short palpebral fissures, increased intercanthal distance, a flattened face, hypoplasia of the philtrum and a thin upper lip
Treatment of choice for eating disorders
CBT
Surgical treatment modality for atrial fibrillation
Cryoablation
MC oral mucosal premalignant lesion
Leukoplakia
biopsy it
Most common malignancy in humans
Basal cell carcinoma
SCC 2nd MC but MC cutaneous malignancy in immunocompromised
Treatment for moderate allergic reaction
Epinephrine IM anterolateral thigh
Antihistamine: cetirizine PO IV (less sedation)
Salbutamol
Treatment for severe allergic reaction
ABCs - get definitive airway
Epinephrine IV or ETT
Antihistamine: diphenhydramine IV
Glucocorticoids: methylprednisolone or prednisolone or prednisone
Large volume of crystalloid
Patients on beta blockers may not respond to epiephrine and may benefit from glucagon reversal
Kidney stone composition
80% calcium oxalate
10% struvite
10% uric acid
What should be given to any patient with altered LOC?
Dextrose
Adults D50W and children D25W
should be given after thiamine to prevent Wernicke’s encephalopathy but do not delay glucose if thiamine is not readily available
If time allows and possible then measure blood glucose first
Who would you not give urgent O2 to in the ED?
Paraquat or diquat herbicide inhalation or ingestion
Free radical formation increases to morbidity
Galactorrhea vs breast discharge
Galactorrhea has fat droplets present
Breast discharge is usually unilateral and may be bloody or serous
Galactorrhea vs breast discharge
Galactorrhea has fat droplets present
Breast discharge is usually unilateral and may be bloody or serous
MCC hypercalcemia in a healthy outpatient
Primary hyperparathyroidism
Surgical excision is definitive treatment
MCC hypercalcemia in hospital admitted patients
Malignancy associated
Most commonly seen in lung, renal, breast, ovarian, squamous tumors, lymphoma, multiple myeloma
How to approach hypercalcemia
Check PTH
If PTH low check phosphate
if phosphate high/normal check vitamin D
If you start to see oliguria or anuria or mental status change it is a medical emergency
What allergy do you need to ask about before giving calcitonin?
FISH
Most common bacterial cause of diarrhea in Canada
Campylobactera jejuni
Associated with Guillain Barret
Rx macrolide or fluoroquinolone
Most common location of Crohn’s
Ileum and right colon
History of aortic graft with abdominal pain associated with bleeding should make you think of what condition?
Aortoenteric fistula
rare but lethal
Diagnose with emergency endoscopy as may require urgent surgery as window of opportunity is narrow
MCC of elevated ALT
Fatty liver
Clinical features of hemochromatosis
Arthralgia
Bronze skin
Cardiomyopathy and cirrhosis
Diabetes
Hypogonadism
MC in Northern European descent
What is TIPS procedure for?
Decrease portalvenous pressure
Stent placed between portal and hepatic vein via transjugular vein catheterization and percutaneous puncture of portal bein
Can be used to stop acute bleeding or prevent rebleeding or treat ascites
Most commonly used as a “bridge” to liver transplantation
CI with severe liver dysfunction, uncontrolled hepatic encephalopathy and CHF
Vast majority of causes of acute pancreatitis are?
Gallstones or ethanol
EtOH MCC chronic
MCC sudden onset of rigid abdomen postoperatively
Perforated viscus
MCC pain out of proportion to physical findings postoperatively
Ischemic bowel
MCC vague pain that subsequently localizes postoperatively
Appendicitis
MCC colicky pain waves postoperatively
Bowel obstruction
MCC LGIB
Diverticular bleed (40%)
MCC severe UGIB
Peptic ulcer disease (55%)
MCC fever within hours after surgery
Inflammatory reaction in response to physiological stress from surgery
Unlikely to be infectious unless necrotizing fasciitis or another infection
Differential: malignant hyperthermia, reaction to blood products recieved at surgery
MCC fever POD 1-2
Atelectasis, early necrotizing fasciitis, aspiration pneumonitis
Acute adrenal insufficiency, thyroid storm, transfusion reason
MCC fever POD 3-7
UTI, surgical site infection, IV site infection (Staph), septic thrombophlebitis, leakage at bowel anastomosis
Likely infectious
MC sign of paraesophageal hiatus hernia
Dysphagia
Least common esophageal hernia
Herniation of all or part of the stomach through the esophageal hiatus into the thorax with an undisplaced GE junction
Boerhaave’s vs Mallory Weiss
Boerhaave is transmural esophageal perforation
Mallory is non transmural esophageal tear
Both associated with forceful emesis
Most common esophageal carcinoma
Squamous cell carcinoma (worldwide)
Adenocarcinoma (Western countries)
Risk factors for esophageal squamous cell carcinoma
Underlying esophageal disease, strictures, diverticula, achalasia
Smoking, alcohol, hot liquids
More common in Black and Asian populations
Risk factors for esophageal adenocarcinoma
Barrett’s esophagus, smoking, obesity, GERD
More common in Caucasians
Most common primary lung tumor type
Bronchogenic carcinoma
Most common type of lung tumor in a nonsmoker
Adenocarcinoma which is a type of non small cell bronchogenic carinoma
Screening with low dose CT is recommended for?
55-74 yo
>30 pack year smoking hx
Current smoker or has quit within 15 years
Do annually up to 3 years
What lung lesion peaks in incidence at 60 yo and appears as ‘popcorn’ pattern of calcification on CXR
Hamartoma
Composed of fat, epithelium, fibrous tissue, cartilage
MCC solitary pulmonary nodule
Benign infectious granuloma: histoplasmosis, coccidiomycosis, TB, atypical mycobacterium
Signs of metastatic gastric carcinoma
Virchow’s node: left supraclavicular node
Blumer’s shelf: mass in pouch of Douglas
Krukenberg tumor: mets to ovary
Sister Mary Joseph node: umbilical mets
Irish node: left axillary node
Location of inguinal hernias
MD: Medial to the inferior epigastric artery = Direct inguinal hernia
LI: Lateral to the inferior epigastric artery = Indirect inguinal hernia
Kehr’s sign
Left shoulder pain due to diaphragmatic irritation from splenic rupture that worsens with inspiration
What are the long term complications associated with a splenectomy?
Sepsis with encapsulated organisms, splenosis (intra abdominal “seeding” of splenic tissue during removal), increased risk of malignancy, DVT, PE
50% mortality
Should be vaccinated with pneumococcal, H influenza and meningococcus 2 weeks pre or post operatively
MC congenital abnormality of the GU tract
Cryptorchidism
Palpable testicle within inguinal canal or testicle which can be milked down into the scrotum (called retractile testis)
Most common presenting symptom of uterine sarcoma
Vaginal bleeding
Rare ~3% of uterine malignancies
Most common type of uterine sarcoma
Leiomyosarcoma
Age 55 but may present in premenopausal women
Often coexists with leiomyomata (fibroids)
Meningitis vs encephalitis
Cerebral function is abnormal in encephalitis (altered mental status, motor or sensory defects, altered behavior or speech, movement disorders) but may be normal in patient with meningitis
There is considerable overlap in the two syndromes
Positive dipstick for leukocyte esterase and nitrites is highly specific for what?
UTI diagnosis
Nitrite negative bacteria
Enterococci
Staphylococci
Nitrite positive bacteria
Enterobacteriaceae (E. coli)
Calculated osmolality equation
(2 x Na) + Glucose + Urea - measures osmolality
mmol/L
Two salts and a sticky BUN
Normal < 10
Causes of increase can be methanol, ethylene glycol, ethanol, polyethylene glycol, manitol, sorbitol
Two MCC of acute kidney injury in hospitalized patients
Prerenal azotemia
Acute tubular necrosis
c-ANCA association
Most commonly associated with clinical picture of granulomatosis with polyangitis
p-ANCA association
Most commonly associated with clinical picture of microscopic polyangitis
Cause of hypertensive encephalopathy? What are the symptoms?
Acute severe HTN (anything over 130/200 seperately)
Papilledema, hemorrhages, exudates, cotton wool spots on fundoscopic exam
Focal neurological symptoms, nausea, vomiting, visual disturbances, seizures, altered LOC
What should be considered in the differential for headache and stroke?
Uncommon but deadly
Central venous sinus thrombosis
Diagnosed with magnetic resonance venography or cerebral CT venogram
Treatment is anticoagulation with heparin then warfarin
High morbidity and mortality
What affect does systemic hypoperfusion have on the brain?
Global cerebral ischemia that primarily affects the watershed areas between the major cerebral arterial territories
Most common sites of hemorrhagic stroke
Putamen, caudate nucleus, thalamus, cerebellum, pons
Steps for treatment of stroke
- BP, volume, glucose, temperature
- Recombinant tissue plasminogen activator within 4.5 h of onset
- Intra arterial mechanical thrombectomy
- Anti platelet therapy (ASA, clopidogrel)
- Anti coagulant
- Withhold antihypertensive therapy for 2-3 d in the setting of acute MI, renal failure, aortic dissection, after non thrombolysed ischemic stroke unless the BP is greater then 220/120
MC intracranial tumor in adults
Metastasis
Lungs < breast < kidney < GI < melanoma
MC PRIMARY intracranial tumor is meningioma that arises from arachnoid c
A compressive adenoma in the pituitary will affect which hormones
GH
LH
FSH
TSH
ACTH
Prolactin
GO LOOK FOR THE ADENOMA PLEASE
Sudden onset of thunderclap headache
Subarachnoid hemorrhage
Can be traumatic or spontaneous
Age 55-60 with very few cases under 45 yo
CT shows hyperdense blood in cisterns or fissues
Manage conservatively, may need open or endovascular repair
50% mortality, 30% have moderate to severe disability after
THe only validated neuroprotective agent is nimodipine
MCC spinal cord impairment
Cervical spondylotic myelopathy
Progressive degenerative process of the cervical spine leading to canal stenosis. Agre related wear and tear affected the neck discs.
MCC hemorrhage in third trimester
Bloody show (represents cerviacal changes or early stages of dilation) or placental abruption
Most common presentation of uterine rupture
Prolonged fetal bradycardia
MCC episodic vertigo
BBPV
Patients often symptomatic when rolling over in bed or moving their head to a position of extreme posterior extension (ie looking up at a tall building)
What is the net step if there has been >2 weeks hoarseness in a smoker?
Laryngoscopy to rule out malignancy
Orphan annie nuclei, psammoma bodies
Papillary thyroid carcinoma
Treat with lobectomy if early or total thyroidectomy if late
Treatment of croup
Racemic epinephrine
Systemic corticosteroids (dexamethasone or prednisone)
Hydrate
Observe closely
May need positive pressure ventilation
Hospitalize if poor response to steroids and persistent stridor
If continued poor response consider different cause ie bacterial tracheitis
Bronchoscopy for definitive diagnosis
Cherry shaped swelling with loss of normal air space on the vallecula on lateral neck radiography
Thumb sign - Epiglottitis
Medical emergency
Rx airway, IV hydration, AB cefuroxime, cerfotaxime, ceftriazone, moist air, extubate when afebrile
Most common congenital heart defect
Ventricular septal defect
Persistent, painless, firm, rubbery, cervical or supraclavicular lymphadenopathy
Hodgkin lymphoma
a/w intussusception, mediastinal mass, head and neck disease
Fever chills night swears weight loss
Which drug is associated with formication?
Meth
Tactile hallucinations
Bilateral hilar adenopathy ddx
Think sarcoid or lympoma
Unilateral hilar adenopathy ddx
Think Neoplasia, TB or sarcoid
Behcet’s characteristics
Multisystem disorder presenting with uveitis, recurrent oral and genital ulcers, venous thrombosis, skin and join involvement
MC in Meditarranean and Asians ~30 yo
Large vessel disease
Vasculitis associated with unequal pulses
Takayasu’s
Chronic inflammation most often of the aorta and its branches
Asian descent most commonly and between 10-40 yo
Increased risk of aortic aneurysm
