Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Clinical Decision Making > Differentials > Flashcards

Differentials Flashcards

1
Q

Sxs & Signs of Chostochondritis

DDx for ?

A

DDx for Chest Pain (Msk cause)

Sharp Anterior Chest Pain@ costochondral
Junctions.

Tenderness on Chest Wall Palpation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

MSK causes of Chest Pain

A

Costochondritis

Rib Fracture (get CXR - old folks can fracture a
rib by coughing and it can make it hurt to
take a deep breath)

Muscular Strain (swelling?bruising?History of 
          (yard work or exertion recently?)

Herpes Zoster (along a dermatome/skin)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Respiratory Causes of Chest Pain

Mainly you’ll sort these from other causes by breath sounds and a cxr…

A

Pneumothorax - Absent/ decr Breath Sounds
on one side/Trauma/Skinny tall young man
Get CXR Unilateral

Pneumonia - Inspiratory crackles & rales often
unilaterally, do special lung tests, lung
excursion may be unequal, Fever?
Productive Cough? Often UNIlateral

Pleurisy - V. painful, Scratchy Friction Rub
sound on insp & expiration. Pain is
relieved by applying pressure over
painful area (temporary). Recent URI?
Burning on Cough? TB? Pneumonia?
Often UNILATERAL

PE - sharp pleuritic chest pain, abrupt onset
Think reasons for embolus formation:
-Recent Surgury (Wearing Cast?)
- Recent Air Travel?
-Smoker?
-Hormone Use?
-Coagulopathy/AFib?
Get BOTH D-Dimer AND spiral CT Scan of
Chest. If D-Dimer is Negative, no PE or
clotting of any kind. If its Positive, you’ve
got a clot but you still don’t know where.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Chest Pain that is exacerbated by forceful breathing:

A

Pleuritic Chest Pain

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

85% of Maximal Heart Rate - How to Calculate this?

A

220 - Age

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Lisinopril:

 - Class?
 - Treats?
 - Common Dose?
 - Side Effects?
 - Recommendations?
A

Lisinopril (Ace Inhibitor) for Hypertension

a. Dose: 20mg/day; 1 pill
b. Side Effects: Persistent dry cough, Hyper Kalemia, go to ER if swelling of lips/tongue or face occurs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Hydrochlorothiazide:

  • Class?
    • Treats?
    • Common Dose?
    • Side Effects?
    • Recommendations?
A

Hydrochlorothiazide (Thiazide Diuretic) for Hypertension

a. Dose: 20mg/day; 1 pill
b. Side Effects: Dehydration, HypoKalemia, Hyponatremia, Gout
c. Recommendation: Stay Hydrated 8 8oz glasses of water /day, Bleeding, Stomach Ulcer

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Metropolol:

  • Class?
    • Treats?
    • Common Dose?
    • Side Effects?
    • Recommendations?
A

Metropolol XL (Beta Blocker) for Angina & HTN

a. Dose: 50mg/day
b. Side Effects: Fatigue, Weakness, Dizziness, Tachycardia if dose(es)missed
c. Recommendations: Advise PCP if any of the above symptoms occurs. If you miss a dose by a few hours, take it. If you don’t recall the missed dose until its almost time for the next dose, skip it. Don’t double dose.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Clopidrogel:

  • Class?
    • Treats?
    • Common Dose?
    • Side Effects?
    • Recommendations?
A

Clopidrogel (Anti-Platelet Agent) to prevent blood clots

a. Dose: 75mg/day 1 pill
b. Side Effects: Bruising, Bleeding, Stomach Ulcer
c. Recommendations: You will bruise and bleed easier than you did before taking clopidrogel. Advise PCP if gums bleed during normal brushing or if bruising/bleeding cause concern

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Atorvastatin:

  • Class?
    • Treats?
    • Common Dose?
    • Side Effects?
    • Recommendations?
A

Atorvastatin (HMG CoA Reductase Inhibitor) for High Lipids

a. Dose 80mg/day
b. Side Effects: Muscle Weakness/Ache; Liver Damage; Type II Diabetes Melli-tus in Women
c. Avoid Alcohol Consumption, Avoid Fast/Processed Foods and Sugar, Drink plenty of water (no soda, no fruit juices, no sugary sports drinks), Exercise to maintain strength. Advise PCP if you experience muscle weakness and/or ache

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Confirmation of Angina on Stress Echo?

A

ST or QRS Segment changes: Depression/Horizontal Change of more than 1mm in a non-Q lead

BP decrease of more than 10mmHg during exercise

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

DDx for Melena

A

UGIB (upper GI Bleed)

  • PUD
  • Varices (esophageal, Gastric, Duodenal - ask about vomiting/coughing up bright red blood)
  • Gastritis
  • Gastric Cancer
  • Epistaxis

*Mallory Weiss Tear - again, this involves vomiting up bright blood but some may go down causing Melena

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Spider Angiomata, what are they and what do they indicate?

A

They are telectangias usually found on the face (often the nose) and/or trunk and are present in Liver Dz (think chronic alcoholism).

Thought to be the result of elevated estrogens.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Palmar Erythema, what is it & what does it indicate?

A

Redness on Thenar and Hypothenar Eminences.

Present in Liver Dz (think cirrhosis/alcoholism andHep C)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What is Caput Medusa and what causes it?

A

Varicosed Veins around the Umbillicus

Sign of Portal Hypertension due to Liver Dz: Alcoholism/Cirrhosis Advanced Hepatitis.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Terry’s Nails, describe & state cause

A

Pale nailbeds in the proximal 1/3, darker thereafter.

Present in Liver Dz: Cirrhosis/Alcoholism Adv. Hepatitis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

How do we obtain orthostatic Vitals?

A

Take Bp & HR with same instrument at 2 minute intervals lying, then seated then standing (if pt can tolerate standing)

A difference of:
20mm Hg between positions in SBP or
10mm Hg DBP or an
Increase in HR of more than 20 bpm indicates Hypotension caused by
Hypovolemia or by
Failure of peripheral vasculature to constrict on change of position (nerve damage)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Most Common Causes of Upper GI Bleeds:

A

Gastritis and PUD (either caused by NSAID use or by H. Pylori).

Esophageal varices from portal hypertension is not Uncommon but usually results in vomiting bright blood or coffee ground vomit as well as a possible (+) guiac

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Hypovolemia with suspicion of a Upper GI Bleed, what to do first?

A

FIX THAT BP!!! Before you run in IV fluids though, ensure you don’t already have pulmonary edema. If you do, or if it develops during hypovolemic resuscitation, run in Lasix too

Two Lg Bore (16 or better 14 gauge) IV ports, one in each antecubital fossa. Run Ringers in both, wide open - you can run in 1L of fluid through a single 14gauge IV in 30 minutes. Keep running it in until BP stabilizes.

Ringers has a crystalline component, nice if you suspect blood loss.

Add a proton pump inhibitor to one bag (Pantoprazole- IV Omeprazole only available in Europe) to assist with stomach sxs.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What logical side effect of bleeding can actually cause stabilization of hypovolemic shock symptoms?

A

Hypotension

When Bp declines, there is less pressure pushing blood out the hole, wherever it is.

If you’re going to restore BP, make sure your CBC results are on the way and you’re ready with Cross type & Match to add packed RBCs to replace those you’ll start pushing out the wound.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Are you going to admit someone with a suspected GI bleed and symptoms of Hypovolemia?

A

Yes. You might get an emergent Upper or lower Endoscopy to ID the location of the bleed and you may even fix it while you’re in there but you’ll have to admit PT until Bp and Hct are stable

You will also get a bedside CXR to visualize the stomach, whether or not there is air under the diaphragm (from a GI perforation) and get some insight into whether there is pulmonary edema or any visible mass.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Why give IV proton pump inhibitor to the suspected UPPER GI bleed?

A

Normalized gastric pH helps support gastric clotting.

Use Pantoprazole (PROTONIX IV), get it on board as soon as you can but 24-48 hrs before endoscopy can really make a difference in whether or not surgical intervention is needed to stop the bleed (hemoclips, vasoconstrictors or cauterization).

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

What is included in a “Coagulation Studies Panel”

A

PT/INR & PTT

Order it whenever you suspect bleeding. You’ll probably order Cross & Match as well, to ensure you can get blood on hand if you need it.

24
Q

Risks of Transfusion:

You need to go over these with your PT when obtaining the Transfusion Consent Form

You need this consent if you think your pt is bleeding. Get it early in case the pt loses consciousness

A

Transfusion reaction
Fever/Chills - non-hemolytic &
self limiting - Most common sort
Acute hemolytic - Check with Coombs test.
Can present as Fever so stop if fever
is noted and do a Coombs and check
urine for blood. If Negative,
you can restart. If (+), begin vigorous
hydration with NS to “flush” Hbg out of
kidneys before renal failure occurs!

anaphylactic, or acute lung injury - the worst case scenario. This is why its important to cross and match beforehand.

If no cross or match possible, give O(-) pRBC or AB Fresh Frozen Plasma (FFP) These are the universal donor types.

25
Q

How to reduce the chance of Anaphlactic Rxn to pRBC transfusion?

A

Get Type & Cross FIRST

Run in IV Benadryl WITH the RBCs

26
Q

How soon should PTs with ongoing upper GI Bleeding have Endoscopy?

A

Within 6 hrs if hemodynamically Unstable
You can stretch it to 24 hrs if stable.

Endoscopy can FIX the bleed with clips, cauterization or injection of vasoconstrictors.

27
Q

Most Common Transfusion Rxn

A

Febrile non-hemolytic

Rule out hemolysis with Coombs and check urine for blood. If both (-) then restart transfusion and keep pt warm/cool as needed depending on if pt has fever or chills.

28
Q

Classic Triad for Acute Hemolytic Transfusion Rxn:

A

Fever
Flank Pain and
Hemoglobinuria

Not often seen together. If you get fever or a local rx or BURNING along the infusion line, do a Coombs and check urine for blood.

If Coombs + or urine has blood STOP the transfusion immediately.

Begin vigorous hydration with isotonic fluids to try to prevent renal failure from hemoglobinuria. Hypotension is also common in the setting of a hemolytic transfusion reaction and may require support with pressors if volume resuscitation isn’t sufficient to maintain blood pressure. A direct antiglobulin test can confirm the diagnosis.

Worst case scenario is you end up in DIC (disseminated intravascular coagulation - bleeding and clotting all over the place- bad, very bad) and Renal Failure. Don’t let this happen.

If you get any transfusion run, stop the blood, get a Coombs and check urine for blood.

29
Q

Acute Hemolytic Transfusion Rxn vs Delayed Transfusion Rxn

A

Essentially the same situation but caused by rxn to “more obscure antigens” Usually comes on 2-10 days post transfusion and is usually milder

30
Q

Describe Transfusion related acute lung injury

A

Transfusion-related acute lung injury (TRALI) is a rare complication of transfusion in which patients develop pulmonary edema after transfusion. It is thought to be immunologically mediated, although the mechanism isn’t well understood. TRALI can be difficult to distinguish from volume overload related to the transfusion. Most cases resolve rapidly, although some progress to the adult respiratory distress syndrome (ARDS).

31
Q

Describe Anaphlactic Transfusion Rxn

A

Pretty much the same as any Anaphylaxis: characterized by shock, hypotension, angioedema, and respiratory distress.

Sometimes occurs in the setting of a blood transfusion, often for unclear reasons. Such a reaction has been well described in some patients with IgA deficiency, who react to the IgA in donor plasma.

An anaphylactic transfusion may occur within a few seconds to a few minutes following the initiation of a transfusion.

32
Q

Coombs test other name:

A

Direct Anticoagulation Test

Tests for Hemolysis

33
Q

Cobblestoning

A

Intermittent swelling of mucosal tissue most notably on the posterior pharynx (caused by post nasal drip) or in the bowel (associated with Crohns) such that the mucosa resembles a cobbled street.

34
Q

Bloody Diarrhea in the setting of acute gastroenteritis sxs: nausea, vomit, possible low grade fever

A

Think invasive pathogen instead of run of the mill viral gastroenteritis.

E.Coli - contaminated veggies/ fecal-oral
3rd wld travel increases this risk

Shigella-food handler contemn /pers 2 pers

Campelobacter - contaminated chicken

Salmonella- Restaurant food/food handlers

C. Dif - Recent hospitalization or Abx rx

35
Q

Dx & Rx Schisto:

A

If your pt has fever, wt loss, malaise, diarrhea and possibly hepato/splenomegaly OR lumbar back pain/headache AND has traveled in tropical regions and been in contact with tropical fresh waters… you need to think schist.

The fecal/rectal egg test is often negative until the colonies have wrought significant damage in whichever organ system(s) they’ve set up in.

Get a CT or MRI of the affected region - biopsy is the only way to find out what will be causing whatever abnormal findings appear (multiple small nodular lesions)

Rx is simple: Praziquantil 60mg/kg for 3 days.
Might be worth it to just dose empirically and see if it works!

36
Q

Centor Criteria?

A

For evaluating potential for strep progenies

1) Fever
2) Exudate, namely Tonislar
3) Tender Anterior Cervical Lymphadenopathy
4) ABSENCE of cough

37
Q

Ipatropium bromide (ATROVENT) nasal spray for?

A

Runny nose - will NOT help with stuffy nose/congestion. It works for runny nose as it is constriction of the vasculature in the inflamed nasal mucosa that SQUEEZE/WEEP out the nasal exudate. Thus, relaxing the smooth muscle vessel walls keeps the fluid IN the vessel. This may, of course, result in increased stuffiness as the nasal mucosa swell….

Anticholinergic is typically used for it’s blockade of muscarinic receptors in the bronchi, thus relaxing smooth bronchial muscles and relieving constriction in moderate Asthma, especially when pt has a heart condition and is unable to risk using Albuterol

Combined with Albuterol (as in Combivent inhaler and DUONEB nebulization treatments) it is of particular use in COPD

Don’t use anticholinergics in Glaucoma or any intestinal obstruction as they’ll make those worse.

38
Q

Anticholinergic Sxs + Contraindications

A

Hot as a hare, red as a beet, dry as a bone, mad as a hatter and blind as a bat,

Mydriasis with hot dry skin, blurred vision, constipation and delirium

Don’t give these in Glaucoma, hyperthermia and GI/Bowel obstruction as they’ll worsen these symptoms.

39
Q

Main bugs in bacterial sinusitis?

Best empiric Rx?

A

H. Flu is #1 Strep Pneumo is #2

Use Augmentin as these two bugs are both resistant to Macrolides and Bactrim.

40
Q

Quick + easy sinusitis physical exam test that does NOT involve percussion?

A

Press penlight to maxillary sinus and see if you can note transillumination on the roof of mouth

41
Q

Main sxs of sinusitis

A

Purulent Nasal Discharge
Maxillary or Frontal tenderness
Upper Tooth pain

42
Q

What’s the concern in men using daily antihistamines or frequent decongestants?

A

They can cause prostate enlargement somehow by relaxing the smooth muscle around the prostate and preventing it from secreting its full dose with ejaculation, need to look further into this. H3 BLOCKERs actually seem to be a potential Rx for prostatiasis, once it already developed…

43
Q

Causes of Unilateral calf swelling

A 
DVT
Cellulitis
Ruptured Popliteal (baker's) Cyst
Muscle Injury
Lymphedema
44
Q

Causes of BiLateral Ankle/Calf Swelling

A

Low Oncotic Pressure (hypo albuminemia)
Third Spacing due to low protein
Nephrotic Syndrome falls here as all
the protein is leaking out holes in the
nephrons

CHF - Fluid overload d/t heart not being able to
push blood through the kidneys at high
enough pressure. There is likely
Low Sodium as well.

45
Q

Cellulitis:

What is it?

What Causes It?

Signs?

Rx?

A
  • Cellulitis is a bacterial infection of the skin and subcutaneous tissues that occurs when organisms breach small breaks in the epidermis.
  • The most common cause is Streptococcus, but Staphylococcus can also cause cellulitis.
  • When cellulitis involves a lower extremity, unilateral edema in the involved area is frequently seen.
  • Other typical findings are redness, warmth and tenderness of the skin and sometimes tender regional lymph nodes.

-Erythema is a typical finding with cellulitis, so its absence makes this diagnosis less likely.
Fever may also be present, but lack of fever doesn’t exclude cellulitis.

Rx: For mild/outpatient w/no abcess (non-prurulent cellulitis) I like:
Cephtriaxone IM (1-2 grams depending on severity) with a script for 5-7 days of:
Dicloxacillin PO (500mg q 6 hs). If allergic to penicillin, can skip the Rocephin and go for oral
Clindamycin (300 mg q 8 hrs).

If it is PRURULENT (abcess, carbuncles, furuncles…) Culture it for MRSA and MSSA and then treat with Vanco IV until culture comes back with better direction.
Vanco IV 15mg q 12 hrs monitor BUN/Cr
Dapto IV 4mg q 12 hrs not if GFR below 30
Linezolid IV 600 mg q 12 hrs
Ceftaroline IV 600 mg, less if GFR under 50

46
Q

Empiric Abx for inpatient MRSA/MSSA risk:

Begin IV AFTER culture sample is taken!!!

A

Vanco IV 15mg q 12 hrs monitor BUN/Cr
Dapto IV 4mg q 12 hrs not if GFR below 30
Linezolid IV 600 mg q 12 hrs
Ceftaroline IV 600 mg, less if GFR under 50

Duration IV is 1-3 days, after debridement and stabilization, switch to oral. May get to change to something narrower if culture comes back with a good sensitivity.

47
Q

Ruptured Popliteal (Baker’s) Cyst

What is it?

Complications of it?

Signs?

Imaging?

RX:

A

Ruptured popliteal cyst

  • Fluid from a leaky or ruptured popliteal cyst can extend in to the posterior calf muscles and cause calf swelling that mimics DVT.
  • Ruptures from large popliteal cysts can compress the popliteal vein and lead to a true DVT.
  • Fluid from a ruptured popliteal cyst extends distally, so thigh swelling argues against this diagnosis.

Imaging: Doppler Sono or just plain Sono can distinguish a cyst from an actual DVT. Also get Xray of the knee, particularly lateral view

Rx: only for symptomatic cysts: Arthrocentesis and injection of glucocorticoids

48
Q

Superficial Thrombophlebitis:

What is it?

Signs?

Imaging?

Rx?

A

Superficial thrombophlebitis

  • Localized tenderness over a firm, linear, palpable vein is a cardinal sign of superficial thrombophlebitis.
  • The tender vein is called a venous cord.

Labs/Tests: Unless you have an IV to blame the start of this on, You are looking for hypercoagulabiity so get a CBC, PT/INR and PTT.

Mild - Aspirin, NSAIDS and warm compresses ELEVATION and TED Stockings

Severe - Same as for mild but use wet heat

If in Anus (Hemorrhoid) you might be able to evacuate the thrombus from the vein - though this is only if it’s onset is recent. Surgery may be required. This will be PAINFUL so medicate your patient!

49
Q

Lymphedema

What is it

Signs, Sxs

Rx

A

Unilateral Extremity Swelling, predominantly leg.

Lymphedema causes leg swelling, but lymphedema is not tender.

Cellulitis and complications thereof are the risk for long term lymphedema. It can be congenital or from surgical/traumatic blockage of the lymph drainage. Can be a complication of obesity.

Rx is EARLY PT: manual lymph drainage and exercise before this gets out of control. Also:

ELEVATION, debridement of keratinous debris and bland moisturization to discourage fissuring.

Compression stockings (40mmHg!!), pneumatic pumps,

50
Q

PE:

Sxs + Signs:

The Triad?

Exam Findings:

Imaging:

Rx:

A 
-Symptoms that occur with PE
sudden onset of dyspnea (73% sensitive for PE)
pleuritic chest pain (44-74%)
hemoptysis (13-28%)
syncope (5%)
leg swelling (17%)

The Triad: SOB/Chest PAIN/ Hemoptysis
The classic triad of shortness of breath/chest pain/hemoptysis occurs only 33% of the time.

-Possible Exam findings
a pleural rub (3% sensitive)
tachycardia (30-70%)
leg swelling (17%)

Findings that are highly specific and increase the likelihood of PE:

  • pleural rub (98% specific)
  • hemoptysis (92% specific)

Imaging: Helical CT of chest, get a doppler sono of the legs too if there is any pain or swelling down there

CXR to rule out pneumonia and CHF or Cancer

Rx: IV Unfractionated Heparin, or LMW Heparin
and Warfarin

If urgent, can use TPA once you clear the pt for cerebral bleeding with head CT.

The permanent fix is surgical implantation of the IVC filter, a badminton birdie shaped filter that gets wedged into the inferior vena cava and breaks up clots before they circulate into the right atrium.

PE usually causes tachypnea which brings on a respiratory alkalosis in acute PE. Eventually, one might get round to a mixed respiratory alkalosis with metabolic acidosis from low 02 but that would be a very late finding

51
Q

VIRCHOW’s TRIAD for…

A

DVT

Hypercoagulable State
       Test Platelets, PT/INR, aPTT
Vascular Injury
        Surgury, Trauma
Stasis
       Inactivity, Bed Rest, Long Flight...

Smoking with Estrogen Use combine into one big risk while alone, either one constitutes minimal risk.

52
Q

D-Dimer

A

D-Dimer is a Fibrin Degradation Product

If over 500, you’ve got Fibrin (a clot) somewhere but it won’t tell you where.

If UNDER 500, you don’t have any clots degrading anywhere and you can RULE OUT clotting

Its not really helpful if you really do think you have a clot. You can go ahead and do it to support the doppler sono or the helical CT if insurance requires but better to skip to the actual test you want.

53
Q

the ONLY PE therapy that actually breaks down the clot:

A

TPA

Tissue
Plasminogen
Activator

Heparin just prevents new clotting as does Warfarin. They prevent platelets from worsening the clot while the body plasters over it with new endothelia.

54
Q

Fondaparinux

A

Selective Xa inhibibitor

Works like Heparin but does not cause Heparin Induced Thrombocytopenia (HIT) as it doesn’t block thrombin itself but rather Factor Xa, which cleaves prothrombin into thrombin.

55
Q

Gold Std for PE vs Most Common Imaging

A

Gold Sdt is Pulmonary Arteiogram - not so easy to set up. Also uses dye so contraindicated in renal dz.

Most common imaging is the Helical Ct - non invasive (mostly, there is dye) but this may miss peripheral PEs and you can’t use it in renal patients.

56
Q

Non-Invasive, non-pharmacuitical that reduces post thrombotic leg swelling by 50%

A

Ted Stockings!!! Use 40 + mmHg though!

57
Q

Clinical indicators of a possible hypercoagulable state

A

Clinical indicators of a possible hypercoagulable state

  • Family history of thrombosis
  • Recurrent thrombosis
  • Thrombosis at a young age (

Clinical Decision Making (1 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions