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EM 1 Flashcards

1
Q

a 48-year-old male with type I diabetes mellitus and end-stage renal disease currently on hemodialysis with dyspnea, cough, and chest pain. He describes the pain as worse during inspiration and when he is lying on his back. The patient reports significant relief of his chest pain by sitting up or leaning forward.

A

pericarditis

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2
Q

PE findings for pericarditis

-often leads to??

A
  • pleuritici CP—–worse with inspiration and laying down— better when pt sits up or leans forward
  • pericardial friction rub–heard when upright/leaning forward
  • diffuse ST seg elevations in precordial leads

often will lead to pericardial effusion *****

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3
Q

MCC of percarditis

A

MC=idiopathic

-SLE
-Uremia
-viral infection—– coxsackie MC
-TB
-RA
-neoplasms
-drugs
POST MI PERICARDITIS 2-5 days post op= DRESSLER

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4
Q

how to diagnose percarditis

A

need two of the following

  1. typical CP—- sharp and pleuritic, improved when sit up/leaning forward
  2. pericardial friction rub—best heard over left sternal boarder
  3. suggestive EKG changes–widespread ST elev in precaridoals and T wave inversion
  4. new or worsening pericardial effusion
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5
Q

type of breathing pattern seen with pt in restrictive percarditis

A

kussmauls sign ——-obstruction to R ventric outflow—— elevating jugular venous and right atrial pressures with inspiration

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6
Q

tx pericarditis

A

ID cause— tx it

  1. NSAIDs, ASA— 7-14 days
  2. corticos for >48 hrs of s/s
  3. ABs for bacerial
  4. pericardiocetesis if effusion
  5. Head at 45 degrees
  6. Pericardial window——– pt can develop tamponade or effusion—- window is cut on the pericardium to allow drainage of fluid
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7
Q

bacterial invovled in endocarditis

  1. acute
  2. IVDU
  3. subacute
  4. prosthetic valve
A

acute=staph A
IVDU=staph A
subacute=S. viridans
prosthetic= staph epidermidis

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8
Q

dukes criteria vs jones criteria

A

DUKE is for endocarditis

JONES for rheumatic fever

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9
Q

tx for Candida endocarditis

A

Amphotericin B

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10
Q

MCC overall of endocarditis

A

Strep viridans

**late complication of valve replacement

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11
Q

PE findings for endocarditis

A
  • splinter hemorrhages in fingernail beds
  • osler nodes—paiful lesions on fleshy portions of extremities
  • roth spots– retinal hems
  • janeway lesions– cutaneous evidence of septic emboli
  • palatal or conjunctival petechiae
  • splenomegaly
  • hematuria

neuro findings— CVA—visual loss, motor weakness, aphasia

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12
Q

diagnosis for endocarditis

-GS?

A

blood cultres— 3 sets 1 hour apart

EKG
LABS— CBC, ESR, RF

transesophageal echocardiogram is GOLD STANDARD

MODIFIED DUKES CRITERIA

  • *definite= 2 major criteria or 1 major + 3 minor OR 5 minor
  • *Possible= 1 major and 1 minor or 3 minor

MAJOR CRITERIA

    • blood cultures
  • single positive blood culture for C. burnetii or antiphase iGG antibody titer >1:800
  • positive echo showing vegetation, abscess or new partial dehiscence of a prosthetic valve
  • new valvular regurgitation– simple change in pre-exist murmur not sufficient

MINOR

  • predisposing heart condition or IVDU
  • Fever > 38C or 100.4F
  • Vascular phenom: arterial emobli, septic pulmonary infarcts, janeway, conjunct hem,
  • immunologic pheomena: glomerulonephritis, Osler nodes, Roth spots, rheumatoid factor (RF) Microbiologic evidence: positive blood culture, but not a major criterion (excluding single positive cultures for coagulase-negative staphylococci and organisms that do not cause endocarditis) or serologic evidence of infection likely to cause IE
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13
Q

who should get AP before dental work

A
  • prosthetic valves
  • hx of IE
  • unrepaired cyanotic congenitial HD or repaired with shunts
  • cardiac transplant with valvue regurg
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14
Q

tx for IE

  • with a native valve and is IVDU
  • with prosthetic valve
  • IVD abusers
A

IVDU= ampicillin 500 mg/h + nafcillin 2 g IV q 4 hr + gentamicin 1 mg/kf

PROSTHETIC= vanco 15 mg/kg + gentamicin 1 mg/kg + rifampin 300 PO

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15
Q

valve affected in IVDU and non IVDU

A 
IVDU= tricuspid 
non= mitral
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16
Q

def diag for stable angina

most sensitive clinical signs to diagnose

tx for stable angina

A

angiography =GS—- useed only for severe cases bc costly
-stress test= most useful and cost effective

horizontal or downslopping ST-segment depression on ECG during attack

stable angina
-BB + nitro
SEVERE= angioplasty and bypass

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17
Q

what is considered a + stress test

A

st seg depression of 1 mm

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18
Q

unstable angina vs NSTEMI vs STEMI

A

unstable= ischemic changes, NO ELEV in troponins, with or without EKG changes for ischemia

NSTEMI= same manifestations as unstable angina, but with elevated troponins—— subendocardial —–ekg changes include ST seg depressions, T wave inversion or BOTH. NO ST ELEVATIONS

SSTEMI= same manifestations as those in unstable angina but with elevations in troponins and EKG Changes—– TRANSMURUAL (full thickness of myocardium)— ST ELEVS

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19
Q

diagnosis of unstable angina

-GS??

A
  1. ekg normal— then do a stress test

ANGIO to diagnose CAD— done if PCI or CABG being considered

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20
Q

tx for unstable angina

A
  1. mod of RF– smoking, BP, lipids
  2. antiplatelet drugs— ASA and/or clopidogrel or ticagrelor
  3. BB
  4. nitro and CCB for symptoms
  5. revasc if s/s persist despite medical tx
  6. ACE and statins
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21
Q

number 1 RF for printzmetal angina

A

smoking

second is cocacine

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22
Q

how to diagnose printzmetal angina

A
  • ***HX of smoking (or no hx of CAD, DM, HTN, HCOL)
  • *** preservation of exercise capacity
  • **EKG: can show inverted U waves, ST seg or T wave abnormals
  • *pain can sligtly be relieved with nitro
    • Positive troponins
  • **CP provoked by IV ergonovine
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23
Q

GS to diagnose vasospastic angina

A

angio with IV provoactive agents like ergonovine into coronary artery

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24
Q

prophylaxtic tx for prinztmetal angina

-what is contraindicated

A

CCB– tx the vasopsasms like amlodipine + long acting nitrates

CONTRA= use of BB like propranlol

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25
Q

AFIB

  • mc in who
  • tx
A
  • elderly
  • etoh

RATE CONTROL
-goal= under 110
drugs= CCB (diltiazem** or verap) or BB (metoprolol)

RHYTHM CONTROL

  • unstable= synchronize cardiovert ****
  • AFIB > 48 days—- anticoagulate for 21 days before cardioversion
  • <48 hours—- cardiovert— get a TEE before to see if clot present

ANTICOAGULATE
-warfarin
target INR=2.5

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26
Q

wide QRS + short PR interval + delta wave =

A

WPW

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27
Q

what is contraindicated for tx of WPW

A

-CCB and BB

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28
Q

causes of cardiac tamponade

A 
ACUTE ONSETS 
trauma 
MI 
aortic disection 
pericadial effusion 
SLOW ONSETS 
CA 
chronic inflammation 
uremic pericarditis 
hypothyroid 
CT disease
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29
Q

becks triad

A

distant heart sounds (muffled heart sounds)
distended jugular veins (JVD)
decreased atrial pressure (hypotension)

***cardiac tamponade

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30
Q

pulsus paradoxus

A

drop 10 mmHg in SPB on inspiration

—- cardiac tamponade

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31
Q

PE findings for cardiac tamponade

A

becks triad– hypot, JVD, muff heart sounds

pulsus paradoxus

electrical alternans— QRS height alternates high to low

CXR— water bottle heart—

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32
Q

diagnosis for cardiac tamponade

-GS

A

GS= echo—- shows diastolic collapse of RV (how to differentaite b/w tamponade and effusion)

effusion= fluid w/o RV collapse

CXR– water bottle heart
EKG– elec alternans

**tamponade is a clinical diagnosis—- echo shows an enffusion and if the RV is collapsed in diastole than tamponade is DX

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33
Q

tx for tamponade

A
  • IVF
  • pericardiocentesis=therapeutic
  • balloon pericardiotomy and pericardial window
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34
Q

pericardial effusion
-PE

-tx

A

-presents similar to percarditis (CP worse laying down.. better leaning forward)

PE

  • distant hear sounds
  • EKg=low voltage QRS and electrical alternans
  • echo shows pericardial fluid WITHOUT RV Collapse in diastole
  • CCR= water bottle heart

tx

  • percardiocentesis if large
  • tx underlying cause
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35
Q

5 DDX for CP in the ED

A
  1. pericarditis
  2. ACS—- CP + SOB + rad to back/shoulders/jaw/arms
  3. PE— pleuritic CP + dyspnea (spiral CT for TOC)
  4. pneumothorax— ipsilateral CP and dyspnea, decr tactile fremitus, deviated trachea, hyperresonance, diminish BS
  5. Thoracic anerusysm/dissection—- tearing, CP rad to back
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36
Q

Absolute contraindications for fibrinolytic use in STEMI include the following:

A
  • prior ICH
  • known stuctural cerebral vasc lesion
  • malignant cerebral CA
  • ischemic stroke within 3 MO
  • suspected aortic dissection
  • active bleeding or bleeding diathesis (exluding menses)
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37
Q

GS for STEMI tx

other tx

A

Beta Blockers + NTG + Aspirin + Heparin + ACEI + REPERFUSION

PCI withint 3 hours of s/s onset (esp 90 mins)
PCI&raquo_space;»»> thrombolytics

thrombolytics

  • done is no access to cath lab or surgery is contra
  • TPA
  • streptokinase

PT SENT HOME ON

  • bb
  • ACEI
  • statin
  • NTG PRN
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38
Q

what drugs can cause edema

A

CCD and alpha 1 blockers– bc they vasodilate

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39
Q

MCC of HF

A
  • CAD
  • HTN
  • MI
  • DM

HF= LV remodeling, dilation, thinning, mitral valve incomptence, RV remodeling

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40
Q

type of breathing pattern seen with HF

A

cheyene stokes —- periodic cyclic respirations

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41
Q

S4 heart sound

A

diastolic HF— EF is normal

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42
Q

S3 heart sound

A
  • hypertrophic cardiomyopathy

* HF— systolic— reduced EF with volume overload

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43
Q

best test for diagnosis of HF

A

echo

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44
Q

systolic LHF tx

A

ACEI + BB + Loop diuretic

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45
Q

Diastolic HF tx

A

ACEI + BB or CCB (do not use diuretics in stable chronic diastolic failure)

46
Q

GS to diagnose RHF

A

right heart cath

47
Q

what is the BEST test for diagnosig CHF

A

echo

48
Q

three specific beta blocekrs used in reducing mortality in HF

A

BETA 1 BLOCKERS

  • metoprolol
  • carvedilol
  • bisprolol
49
Q

HTN emergency

A

> 180/120 WITH impending or progressing end organ damage

tx

  • red bp by 25% in 1 hour
  • IV sodium nitropurissde
50
Q

HTN urgency

  • define
  • tx
A

> 180/120 without end organ damage

-clonidine

51
Q

Malignant HTN

  • define
  • tx
A

diastolic reading >140 assoc with papilledema and encephalopathy or nephopathy

tx
-sodium nitropurisside/hydralazine/Clevidipine

52
Q

MCC of cardiogenic shock

A

MI
HF
cardiac tamponade

53
Q

what happens to pulmonary cap wedge pressure in cardiogenic shock

A

it increases

>15 mmHg

54
Q

define orthostatic hypotension

A

Drop of > 20 mm Hg systolic, 10 mmHg diastolic, 15 BPM increase in pulse 2-5 minutes after a change from supine to standing

55
Q

ankle brachial index results for periph vascular disease

A

<0.9

56
Q

PE findings for PVD

A
  • LE hair loss
  • birttle nails
  • pallor
  • cyanosis
  • shiny atrophic skin
  • claudication
  • hypothermia
  • ulcers=pale to black, well circumscribed and PAINFUL, laterally and distally
57
Q

DX for PVD

-GS?

A

arteriography/ angiography for PAD

58
Q

tx for PAD

A
  1. RF control— stop smoking, DM/HTN/hyperlidi controlled
  2. exercise–walk to the point of claudication
  3. platelet inhibs— ASA/Clopidogrel/cilostazol
  4. ACEI/statins
  5. exercise

if all that fails– revasc with PTA, bypass grafts, stenting

59
Q

PE findings for venous insufficiency
RF
DX
TX

A

Stasis deramtitis

non healing ulcers at medial malleolus

discomofrt, edema

RF
advancing age, family history of venous disease, ligamentous laxity (eg, hernia, flat feet), prolonged standing, increased BMI, smoking, sedentary lifestyle, lower extremity trauma, prior venous thrombosis (superficial or deep), high estrogen states, and pregnancy

DX

  • clinical
  • get US to R/O DVT
  • DD

TX
-compression, wound care and rarely surgery
-elevate legs
leg exercies

60
Q

opening snap

A

Mitral stenosis

61
Q

mid systolic click

A

MVP

MR

62
Q

when do surigcal repair for AAA

A

> 5.5 or expands >0.6 cm per yr

63
Q

monitoring for AAA

PT should be on what med

A

annually if > 3 cm
every 6 MO if > 4cm

BB*****

64
Q

AAA vs dissection

A 
AAA= all 3 layers 
disection= inner layer
65
Q

sudden tearing CP b/w scapula and diminished pulses

A

Aortic dissection

66
Q

older male >60 YO with severe back or abd pain
+syncope
+hypotension and tender abd mass

A

AAA

67
Q

aortic dissection

-ascending vs descending

A

ascending —- surgical emergency

descending— medical tx– BB unless complicated present

68
Q

Type A aortic dissection

A

Proximal

-surgical managmenet

69
Q

Type B aortic dissection

A

Distal

-medical management

70
Q

GS for evaluation of aortic dissection

A

MRI angio

71
Q

variation in pulse b/w r and l arm

A

aortic dissection

72
Q

CXR shows widened mediastinum

A

aortic dissection

73
Q

GS For eval of AAA

A

angiography

74
Q

screening for AAA

A

one-time screening for abdominal aortic aneurysm by ultrasonography in men ages 65 to 75 years who have ever smoked

75
Q

test of choice for throacic anuerysm

A

CT

76
Q

What size should you refer AAA to vascular surgeon?

A

> 4.5 cm

77
Q

when is immediate surigcal repair needed for AAA

A

> 5.5 or >0.5 cm expansion in 6 MO

even if asymptomatic

78
Q

GS for diagnosis of aterial embolism/thrombosis

A

angioraphy

79
Q

GS for diagnosis pheblitis/thrombophelbitis

A

venous duplex US

80
Q

Virchows triad

A

DVT

  • stasis
  • enodthelial damage (surgery).
  • hypercoag state
81
Q

sprain =

strain =

A

sprain=liagments

strain=muscles+tendons

82
Q

+spurling test

A

cervical sprain
+sitff
+pain in neck
+paraspinal muscle tenderness and spasm

83
Q

tx for cervical sprain

A

c collar for 2-3 days, ice, heat, analgesics, gentle ROM

84
Q

back strain

A

thoracic and lumbar
-lifiting, twisting or strenuous activity

NO RADICULAR S/S **

no neuro changes—– NO PAIN BELOW KNESS

tx= NSAIDs, heat, ice PT, exercise, bed rest <2 days

85
Q

pain with direct pressure on knee (when PT kneels it hurts)

swelling over patella

A

prepatellar bursitis

86
Q

what is common in wrestlers

A

prepatellar bursitis

**also worry about septic bursitis—- get aspiraiton with gram staining+ culture

87
Q

tx for prepatellar bursitis

A

NSAIDs, compressive wraps

+/- aspiration and immobilization

88
Q

atheletes who particiapte in jumping activitis

A

patellar tendinitis

-anterior knee pain with patellar tendon tenderness

89
Q

pain at biceps groove

-pain with resisted supination of elbow

A

biceps tendonitis

90
Q

how to diagnose caudia equina

A

-emergent MRI

if MRI not available— then CT myelography

91
Q

CP worse with deep breaths or coughing
CP worse with upper body movement

UNILATERAL cp

A

costochronditis

92
Q

costochronditis

  • dx
  • tx
A

DX

  • reproducible CP
  • XR, bone scan, vit D levels, bipsyp ECG— to R/O other stuff if necessary
  • re-consider this if absence of local tenderness to palpation
  • PT > 35 YO work up for CAD—EKg, troponins
  • PE can mimic this———

TX

  • anti-inflammatories—-NSAIDs, tylenol
  • apply heat with compression
  • PT, local steroid injectios
93
Q

GS for DVT DX

A

venography

— been largelt replaced with US

94
Q

Shoulder dislocation

-mc?

A

MC= anterior—> FOOSH–>abduction + eternally rotated

95
Q

assoc conditions with shoulder dislocations

A

BANKART LESIONS—- fx of anterior inferior glenoid following impact of humeral head against glenoid

HILL SACHS LESIONS—- dent in the humeral head— compression chrondral injury of posterior superior humereal head

axillary nerve injury*** C5-6

labrum tear

96
Q

direct fall onto the shouler

A

clavicular fx

97
Q

mc assoc condition with anterior shoulder dislocation

A

hill sac lesion

98
Q

MC type of claviular fx

A

middle third (right in the middle basically)

99
Q

tx for claviuclar fx

A

-simple arm sling or figure 8 sling for 4-6 weeks

consult ortho is proximal 1/33 fx

100
Q

fall on the shoulder

PE Deformity: elevation of clavicle and point tenderness and pain with cross chest testing

A

AC joint separation

101
Q

DX for AC joint separation

A

XR with patient holding a weight to assess level of injury

102
Q

Shoulder pain with overhead activity or at night when lying on arm

A

rotator cuff tear

103
Q

dx for rotator cuff tear

A

MRI

104
Q

list muscles of rotator cuff

A

suprasinatus
subscapularis
infraspinatus
teres minor

105
Q

humeral fracture

  • mc in who
  • mc involve what else injured?
A
  • elderly who fall

- MC site for radial nerve injury

106
Q

xray shows posterior fat pad sign

A

supracondylar fracture

107
Q

supracondylar fracture

-worry about

A

compartment syndrome

brachial artery

108
Q

anterior fat pad sign

A

supracondylar fracture

109
Q

posterior fat pad sign

A

distal humeral fx

110
Q

pt punched a wall or generally punch with clenched fist

A

boxers fx

111
Q

insidious onset of dull aching pain localized to groin, lateral hip or butt

A

AVN

112
Q

RF for AVN

A
  • sickle cell
  • trauma
  • steroid use

EORs (15 decks)

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