EM Clerkship Flashcards
1
Q
Creatinine phosphokinase is a marker of
A
skeletal muscle damage and serum elevation >1,000 U/L confirms the dx
2
Q
Drug induced rhabdo
1. Statins, fibrates, colchicine, ethanol, cocaine
2. cocaine, amphetamines
3. ethanol, opioids, benzos
A
- direct myotoxicity -
- Vasoconstrictive ischemia
- Prolonged immobilization (compression ischemia)
3
Q
Pain are associated with internal or external hemorrhoids?
A
external
4
Q
Initial management for external hemorrhoids includes
A
- sitz baths
- stool softeners
- topical anesthetics
5
Q
Acute cervicitis
1. etiology: chlamydia trachomatis, neisseria gonorrhoeae, noninfectious (foreign object, latex, douching)
2. Asymptomatic, mucopurulent d/c, postcoital/intermenstrual bleeding, friable cervix
3. Evaluation?
4. Management?
A
- NAAT and/or wet mount microscopy
- Empiric treatment: ceftriaxone and doxycycline
6
Q
- transmitted via undercooked poultry
- clinical features: fever, abd pain, diarrhea (mucoid +/- blood), pseudoappendicitis
—> What is this?
—> tx
—> complications
A
Campylobacter gastroenteritis
—> supportive care (usually self limited <7), antibiotics only in severe or high risk cases
—> Guillain-Barre syndrome, reactive arthritis
7
Q
- Loss of pain and temp in the ipsilateral face (spinal trigeminal tract) and contralateral trunk/limbs (spinothalamic tract)
- Ataxia (inferior cerebellar peduncle) and nystagmus (vestibular nucleus)
- dysphagia and dysphonia
- ipsilateral horner syndrome (sympathetic tract)
A
Lateral medullary (wallenberg) syndrome
8
Q
Acute cholangitis
1. What is it?
2. clinical presentation (charcot triad vs reynolds pentad)
3. Dx
4. Tx
A
- ascending infection due to biliary obstruction
- Chacot triad (fever, jaundice, RUQ pain), Reynolds pentad (+/- hypotension, AMS)
- Abnormal LFTs (increased direct bilirubin, alkaline phosphatase, mildly increased aminotransferases)
—biliary dilation on abd U/S or CT scan - Antibiotic coverage of enteric bacteria. ERCP within 24-48 hr
9
Q
what does acetaminophen overdose do to labs?
A
transaminases elevations are expected to be in the thousands
10
Q
Alcoholic toxicity can cause alcohol hepatitis –> what is the ratio of aspartate and alanine aminotransferase ratio?
A
Aspartate aminotransferase to Alanine aminotransferase ratio of >=2
11
Q
What lab value is elevated and most reliable in pancreatitis?
A
lipase
11
Q
- SAAG >= 1.1 g/dL
- SAAG <1.1 g/dL
A
Serum to ascites albumin gradient
1. portal hypertension (often cirrhosis and heart failure) –>the hydrostatic pressure increases, causing more fluid to leave the circulation and enter the peritoneal space. This increases the SAAG because the serum albumin becomes more concentrated.
- other causes (malignancy, pancreatitis, nephrotic syndrome, TB)
12
Q
How to treat intussusception in children 6-36 months with periodic abdominal pain and target sign on U/S
A
air or water soluble contrast enema
13
Q
Desmopressin is an analogue of what hormone?
A
Antidiuretic hormone –> ADH increases the amount of water the kidneys reabsorb from urine. ADH binds to receptors in the collecting duct, which causes the cells to insert aquaporins into their membrane. Aquaporins are channels that allow water to pass through and be reabsorbed into the bloodstream.
—> can lead to SIADH and lead to hyponatremia
14
Q
Soft signs of vascular injury (unexplained hypotension, stable hematoma, reduced pulse) warrant….
A
CT angiogram for further evaluation
15
Q
–> Diabetic ketoacidosis is sign of what type of diabetes
–> Hyperosmolar hyperglycemic state is a sign of what type of diabetes?
A
- Type 1
- Type 2
16
Q
Persistent pneumothorax and large air leak despite tube thoracostomy in setting of blunt chest trauma suggest….
- what can be used to confirm dx
A
- tracheobronchial rupture
- Bronchoscopy can confirm
17
Q
Preeclampsia patients are at an increased risk of stroke so new focal neurologic deficits should be evaluated with..
A
CT scan of the head
18
Q
- purulent monoarthritis OR triad of tenosynovitis, dermatitis, migratory polyarthralgia
- what is this?
- Treated with 3rd generation cephalosporin intravenously
A
1.disseminated gonococcal infection
—> detection of Neisseria gonorrhoeae in urine, cervical, or urethral sample
Polyarthralgia: Asymmetric pain in multiple distal and proximal joints. Examination usually reveals pain with movement and palpation; multiarticular joint swelling, erythema, and warmth are uncommon.
Pustular rash: Most patients have 2-10 pustular or vesiculopustular lesions on the distal extremities; trunk lesions can also occur. The palms and soles may or may not be affected.
Tenosynovitis: Patients report pain over the flexor tendons of multiple distal joints (eg, wrists, ankles, fingers, toes) and/or pain with passive range of motion of the joint.
19
Q
effects from a certain drug type
- mental status changes
- seizures
- tachycardia
- hypotension
- cardiac conduction delay
- anticholinergic effects (e.g. dilated pupils, hyperthermia, flushed and dry skin, intestinal ileus)
-what drug overdose is this?
A
- TCA overdose
–cardiac conduction delay QRS >100 msec
20
Q
- deposition of IgA, C3 and fibrin in small vessels –> vasculitis
- palpable purpura/petechiae on lower extremities, arthritis/arthralgia, abd pain, intussusception, renal disease, scrotal pain and swelling
- Hematuria +/- RBC casts and/or proteinura
- supportive care for most patients (hydration and NSAIDS)
A
IgA vasculitis (Henoch-Schonlein purpura)
21
Q
management of ascites in cirrhosis
A
- spironolactone with furosemide
- alcohol abstinence, sodium restriction
22
Q
Acute coronary syndrome - made up of what 3 things
A
- STEMI
- NSTEMI
- unstable angina
23
Q
Acute coronary syndrome
1. first is ECG
2. this differentiates between ST or non ST elevation
3. Non-ST elevation —> what differentiates between unstable and NSTEMI?
A
- Positive cardiac markers = NSTEMI
- negative cardiac markers = unstable angina
24
NSTEMI and unstable angina management is the same
1. goals include relief of ischemic pain, assessment and maintenance of hemodynamic stability, and prevention
2. what 4 agents are used???
1. antiplatelet agents (e.g. aspirin plus clopidogrel, ticagrelor, or prasugrel) AND anticoagulant therapy (e.g. unfractionated heparin, enoxaparin, fondaparinux) to prevent intracoronary thrombus propagation and abrupt vessel occlusion
2. beta blocker (metoprolol, atenolol) - to reduce myocardial oxygen demand and risk of ventricular arrythmia
3. nitrates to reduce myocardial oxygen demand, reduce preload, relieve ischemic pain
4. High intensity (atorvastatin, rosuvastatin)
25
Dislocation associated with humeral neck fracture typically requires (closed or open repair?)
- Open surgical repair to avoid further displacement or avascular necrosis to humeral head
---for patients with no associated fracture and no evidence of neurovascular injury, closed reduction under sedation can be attempted
26
benzodiazepines MOA
enhance the inhibitory effect of GABA through positive allosteric modulation at the GABA A receptor
27
Unstable angina or non-ST elevation MI is managed with what 5 medication types?
1. Antiplatelet (aspirin + clopidogrel, ticagrelor, or prasugrel)
2. anticoagulant (unfractionated heparin, enoxaparin, fondaparinux, bivalirudin)
3. Beta-blockers (metoprolol, atenolol) - to reduced myocardial oxygen demand
4. Nitrates - to reduced myocardial oxygen demand, relieve ischemic pain, and reduce preload
5. High intensity statins
28
Dislocation associated with humeral neck fracture typically requires what type of reduction/repair?
open surgical
29
(IMAGING) of the upper extremity is indicated for patients with signs of arterial injury (e.g. large hematoma, diminished pulses) but is not needed for patients with intact neurovascular examination
CT angiography
30
Differentiate between TRALI and TACO
1. TRALI (transfusion-related acute lung injury) - rare but life threatening complication of blood product transfusion marked by a massive release of cytokines, reactive oxygen species, and other inflammatory mediators from neutrophils in pulmonary vasculature in response to transfused blood components
---> begin within a few hours of transfusion
---> pulmonary edema with hypoxia, tachypnea, and bilateral pulmonary infiltrates
2. TACO (transfusion associated circulatory overload)
----> Hydrostatic edema, or cardiogenic edema, caused by volume overload
----> Distended neck veins
31
(blank) is rapidly progressive cellulitis of the submandibular and sublingual spaces - source of infection is most commonly an infected mandibular molar
Ludwig angina
32
Infants age (BLANK) as well as those with signs of intracranial infection or prolonged altered mental status, should undergo lumbar puncture to evaluate for meningitis
<6 months
33
What is treatment of ischemic stroke in patients with sickle cell disease
exchange transfusion
- replacing sickled cells
34
Cardiac beta-blocker toxicity involves reduced cAMP activity in SA and AV nodes and contractile cardiomyocytes resulting in bradyarrhythmia and hypotension --> (BLANK) counteracts by increasing cAMP activity
Glucagon
35
HAPE - high altitude pulmonary edema
- mechanism
Normal response to local alveolar hypoxia is hypoxic pulmonary vasoconstriction which diverts blood flow from poorly to better aerated alveoli, preserving ventilation-perfusion matching
---low ambient partial pressure of inspired oxygen at high altitude causes global HPV throughout the lungs
36
what type of precaution is needed for measles?
airborne precautions for protection against small respiratory particles
--- small particles can remain suspended in air for hours in closed space (e.g. treatment room) due to their small size (<= 5 um)
37
management of hemorrhagic stroke
Three steps
1. blood pressure control - usually with a reversible and titratable antihypertensive such as IV nicardipine or labetalol (systolic 140-160)
2. Reversal of anticoagulation -- vitamin K is given to warfarin patients, protamine sulfate to patients on heparin
3. Regulation of ICP - elevation of head of bed, sedation, osmotic therapy
38
1. ipsilateral hemiparesis and diminished proprioception, vibratory sensation, and light touch at the level of the spinal cord injury and below
2. contralateral diminished pain and temperature sensation 1-2 levels distal to the cord injury and below
what is this?
Brown-sequard syndrome
---typically due to hemisection (disruption of half) of the spinal cord
39
clinical features
- Severe sore throat
- Fever
- Hot potato voice
- Dysphagia
- often unilateral pharyngeal pain
----> exam
- trismus (tightened jaw muscles)
- muffled voice
- uvular deviation
what is it?
what is treatment?
peritonsillar abscess
---tx involves needle aspiration or incision and drainage plus antibiotic therapy
40
Initial management of frostbite starts with rapid rewarming of affected tissues --- if persistent signs of tissue ischemia what are next step/studies?
Angiography or technetium-99m scintigraphy to identify who would benefit from thrombolysis
41
Type of bias
1. anchoring
2. availability
3. confirmation
4. framing
1. fixating on initial impressions to make a diagnosis
2. allowing recently seen or memorable cases to sway diagnosis
3. emphasizing evidence that supports presumed diagnosis and overlooking information that supports other diagnoses
4. allowing diagnostic approach be influenced by context and presentation of information (abd pain dx as withdrawal in pt described as drug seeking but actually SBO)
42
1. 3-4 days of nonspecific findings (fever, myalgia, malaise)
2. Rash that often starts as maculopapular lesions on the ankles and wrists and spread toward the center of the body --> progresses to petechial lesions
3. LABS: Thrombocytopenia, decreased sodium, elevated aminotransferase levels
what is this? + treatment?
Rocky mountain spotted fever --> doxycycline
43
Ureteral stones (size) mm pass spontaneously
<= 5 mm
--give oral analgesics and increase oral fluid intake
44
Chemical burns from hydrofluoric acid (HF) can have direct cardiotoxic effect --> what topical treatment should be used?
calcium gluconate gel --> calcium binds to toxic fluoride ions to prevent further damage
--cardiac toxicity includes electrolyte disturbances and cardiac arrhythmias
45
acute iron poisoning
- abd pain, hematemesis, diarrhea, shock, liver necrosis
---> treatment?
deferoxamine
whole bowel irrigation
--> diagnostic findings can include anion gap metabolic acidosis
--> elevated serum iron
46
Mild vs mod/severe stridor and treatment difference
1. Mild = stridor present only with agitation
--> single dose of oral glucocorticoid (e.g. dexamethasone)
2. Mod/severe - stridor even at rest
--> nebulized racemic epinephrine in addition to glucocorticoids
47
Acute mesenteric ischemia
Presentation:
- rapid onset of severe periumbilical pain, out of proportion to exam findings
- hematochezia is late finding
what are preferred diagnostic imaging?
1. CT mesenteric angiography (preferred) or MR angiography
Labs:
- leukocytosis
- elevated amylase and phosphate levels
- metabolic acidosis (elevated lactate)
48
- Acute onset of severe eye pain
- Blurred vision
- Nausea and vomiting
- Pupillary dilation, red eye
what is this?
treatment?
Angle closure glaucoma
-- tonometry reveals increased intraocular pressure
--IV acetazolamide can lower intraocular pressure
49
What are 6 Ps of acute limb ischemia?
--immediate treatment?
Pain, pallor, paresthesia, pulselessness, poikilothermia (cool extremity), paralysis (late)
--> anticoagulation (e.g. heparin) - prevents further arterial thrombus propagation
--> some may improve clinically and some may require percutaneous thrombolysis (e.g. alteplase) or surgical thrombectomy to restore perfusion
50
(blank) is most common arrhythmic cause of syncope and sudden cardiac death
ventricular tachycardia
---sudden onset with lack of warning signals (non prodromal)
51
Heat exhaustion vs exertional heat stroke
1. hyperthermia (typically <= 104F) associated with weakness, dizziness, profuse sweating, headache, and/or nausea. Mentation stays normal
2. exertional heat stroke - has CNS dysfunction and above 104F
52
SIADH etiologies
1. CNS (blank)
2. Medications (e.g. carbamazepine, SSRIs, NSAIDs)
3. Lung (blank)
4. Ectopic ADH secretion (BLANK)
5. Pain and/or nausea
1. CNS disturbance like stroke, hemorrhage, trauma
2. -
3. Lung disease (e.g. pneumonia)
4. Ectopic ADH secretion such as in small lung cancer
5. -
53
SIADH
Lab findings
1. Na levels
2. serum osmolality
3. urine osmolality
1. hyponatremia
2. serum osmolality <275 mOsm/kg (hypotonic)
3. urine osmolality >100 mOsm/kg H2O
54
Acute aortic dissection suspicion
1. what therapy should be started for high suspicion
2. what confirmatory imaging
3. Type A vs Type B - what are they and their management
1. IV beta blockade (e.g. esmolol, labetalol)
+ pain control (e.g. morphine)
2. CT angio of the aorta or TEE other modality (chest x-ray for initial concern)
3. Type A is ascending aorta involved -emergency sx repair
--> Type B is descending aorta -- admit for BP control and monitoring
55
what are symptoms of anticholinergic toxicity?
Red as a beet - flushing
Dry as a bone - dry skin and mucous membranes
Blind as a bat - mydriasis (dilated pupils)
Mad as a hatter - delirium
Hot as a hare - fever
Full as a flask - urinary retention
an EKG should be done to evaluate for possible QRS interval or QTc prolongation - bc TCAs (having anticholinergic toxicity) can cause this
56
Bronchiolitis is a lower respiratory tract infection in children age <2 that presents with cough, crackles/wheezing, and increased work of breathing - viral induced inflammation of small, distal airways, bronchiolar obstruction from sloughed epithelial cells, leukocytes, and mucous
Xray findings include
Tx?
1. hyperinflation, peribronchial cuffing, and increased interstitial markings
2. pts without hypoxia or persistent respiratory distress are managed outpatient with supportive care and close follow up
RSV is common cause
57
aplastic crisis
1. change in hgb
2. reticulocyte count
3. no splenomegaly
1. drop in Hgb
2. reticulocyte count <1%
58
Colles fracture
- what neurovascular structures are at risk?
distal radius fracture - typically occurs from a fall on an outstretched hand and are common in elderly; osteoporosis is a risk factor
-- radial artery and median nerve can get compressed or injured
- when neurovascular compromise is noticed then its an indication for immediate fracture reduction
59
Muscarinic toxicity (DUMBELS) - (cholinergic toxicity)
**cholinergic receptors have two types (nicotinic and muscarinic)
Diarrhea/diaphoresis
Urination
Miosis (constriction)
Bronchospasms, bronchorrhea, bradycardia
Emesis
Lacrimation
Salivation
60
Nicotinic toxicity - (cholinergic toxicity)
**cholinergic receptors have two types (nicotinic and muscarinic)
Muscle weakness
Paralysis
Fasciculations
61
MOA of organophosphates
Inhibit acetylcholinesterase which increases cholinesterase activity --> leading to overstimulation of muscarinic and nicotinic receptors
62
Treatment of organophosphate poisoning
- Atropine reverses muscarinic symptoms
- Pralidoxime reverses nicotinic and muscarinic symptoms (give after atropine)
63
Physostigmine MOA
acetylcholinesterase inhibitor - used for anticholinergic toxicity
64
Symptoms of acute and chronic salicylate toxicity include ---
Treatment in patients with altered mental status, pulmonary edema, renal failure, and persistent acidosis
1. vomiting, tinnitus, pulmonary edema, hyperthermia, tachypnea, and anion gap metabolic acidosis
2. hemodialysis
65
anion gap equation
(Na ) - (Cl + HCO3) =
normal range is 4-12
66
What happens with fibrinogen and d-dimer in DIC?
There is widespread deposition of fibrin and platelet rich thrombi, which rapidly consumes fibrinogen and is associated with D-dimer elevation
--low fibrinogen
--elevated D-dimer
67
epiglottitis
1. microbiology
2. clinical features
3. xray findings
4. management (endotracheal intubation, antibiotics) -- what antibiotics?
1. H influenzae type b
2. distress (tripod position, sniffing position, stridor), dysphagia, dysphonia, drooling, high fever
3. thumb sign
4. ceftriaxone and vancomycin
68
Hypotension
Tachycardia
Jugular venous distension
---> becks triad: hypotension, JVD, muffled heart sounds
---> pulsus paradoxus (>10 mmHg decrease in SBP with inspiration)
--> likely what?
Acute cardiac tamponade
69
Best way to transport amputated digit?
wrapped w/saline moistened gauze and directly covered by ice on all sides
70
When using lidocaine what is the purpose of
1. sodium bicarbonate
2. epinephrine
1. raises the solution's pH, reducing the pain associated with injection and increasing onset of analgesia
2. epinephrine causes vasoconstriction, decreased bleeding, reduced systemic absorption of lidocaine and prolonged analgesic effect
71
animal bites - first line therapy is ... (against pasteurella multocida, anaerobes)
amoxicillin-clavulanate (augmentin)
72
neonatal sepsis
1. three common bugs
2. treatment - parenteral antibiotics?
1. GBS, E coli, Listeria
2. Ampicillin and gentamicin
73
- petechiae, ecchymosis
- mucosal bleeding
- isolated thrombocytopenia (<100,000)
- few platelets (size normal to large) on peripheral smear
what is it?
Immune thrombocytopenia due to platelet autoantibodies
74
Antibiotic used for acute bacterial prostatitis (fever, dysuria, and a swollen, tender prostate)
6 weeks of therapy with TMP-SMX or a fluoroquinolone (e.g. levofloxacin)
75
HHS (hyperosmolar hyperglycemic state)
- glucose >600 mg/dL (frequently >1,000 mg/dL)
1. initial treatment is aggressive hydration with normal saline
2. IV insulin
3. At what potassium level should K replacement be given?
3. K <5.3 mEq/L ; give potassium repletion
76
Primary adrenal insufficiency (PAI) - Addison disease
- what is this?
- clinical features
- labs
--> Na
--> K
1. aldosterone deficiency
2. fatigue, weakness, anorexia/weight loss
- nausea, vomiting, abd pain
- salt craving, postural hypotension
- hyperpigmentation
3. Hyponatremia
Hyperkalemia
eosinophilia
77
does epididymitis improve with elevation of the testis?
yes - does not improve with testicular torsion
78
indication for immediate laparotomy
1. hemodynamic instability
2.
3. evisceration (bowels out of body)
4.
2. peritonitis (rigidity, rebound tenderness)
4. impalement
79
spontaneous abortion types
1. Missed
2. Threatened
3. Inevitable
4. Incomplete
5. Complete
1. no vaginal bleeding, closed cervix, no fetal cardiac activity or empty sac
2. vaginal bleeding, closed cervix, fetal cardiac activity
3. vaginal bleeding, dilated cervix, products of conceptions may be seen/felt at or above cervical os
4. vaginal bleeding, dilated cervix, some products of conception expelled and some remain
5. vaginal bleeding, closed cervix, products of conception completely expelled
80
Management of corneal abrasion
1. traumatic or foreign body abrasion
2. contact lens abrasion
1. remove foreign body; topical antibiotic (e.g. erythromycin, polymyxin/trimethoprim)
2. topical antipseudomonal antibiotic (e.g. ofloxacin, ciprofloxacin, tobramycin)
81
Painful, red eye with corneal opacification and ulceration --> consistent with (BLANK), which is an ophthalmologic emergency
--this is a corneal infection that can be bacterial, viral, or fungal
--treatment?
Bacterial keratitis - can also come with mucopurulent drainage and ulceration of conrea
--> Most commonly due to staph aureus and pseudomonas --> topical antibiotics (e.g. moxifloxacin)
82
Illicit drug clinical features
1. violent behavior
2. dissociation
3. hallucinations
4. amnesia
5. nystagmus (horizontal or vertical)
6. ataxia
what drug is this?
PCP (phenycyclidine) (hallucinogen)
83
Illicit drug clinical features
1. visual hallucinations
2. euphoria
3. dysphoria/panic
4. tachycardia/hypertension
what drug is this?
LSD (hallucinogen)
84
Illicit drug clinical features
1. Euphoria
2. agitation/psychosis
3. chest pain
4. seizures
5. tachycardia/hypertension
6. mydriasis
what drug is this?
cocaine (stimulant)
85
Illicit drug clinical features
1. violent behavior
2. psychosis, diaphoresis
3. tachy/htn
4. choreiform movements
5. tooth decay
what drug is this?
methamphetamine (stimulant)
86
Illicit drug clinical features
1. euphoria
2. depressed mental status
3. miosis
4. respiratory depression
5. constipation
what drug is this?
heroin (opioid)
87
Exudate vs transudative pleural effusion
-light criteria-
1. exudate
- pleural protein/serum protein ratio
- pleural LDH/serum LDH ratio
2. transudate ratios
1. >0.5
2. >0.6
transudate - opposite to this
88
Exudate vs transudate causes
1. exudate: infection, malignancy, rheumatologic disease, pulmonary embolism, pancreatitis, post-CABG
2. heart failure, cirrhosis, nephrotic syndrome, constrictive pericarditis
89
Patients with hyperkalemia who develop arrhythmias or other significant ECG changes should be treated rapidly with (BLANK)
IV calcium gluconate or calcium chloride
---ECG findings: peaked T waves, progressive lengthening of PR interval, absent/flattened P waves, QRS complex widening
90
magnesium toxicity
- neurovascular changes
- cardiovascular changes
- calcium changes
1. decreased reflexes, weakness, paralysis, respiratory failure
2. hypotension, bradycardia, conduction defects
3. hypocalcemia
91
(BLANK) occlusion presents with acute or subacute painless monocular visual loss
-- fundoscopic exam shows a "blood and thunder" appearance consisting of optic disk swelling, retinal hemorrhages, dilated veins, and cotton wool spots
central retinal vein occlusion
92
bacterial endophthalmitis
1. etiology
2. clinical features
3 Tx is with intravitreal injection of antibiotics, virectomy for severe cases
1. bacterial infection of the aqueous humor and/or vitreous
2. decreased vision and eye discomfort, conjunctival injection and edema, purulent haziness or layering of leukocytes (hypopyon) in anterior chamber
93
Scleroderma renal crisis is characterized by acute onset of HTN and AKI in patients with systemic sclerosis
-what medication can help improve renal function and normalize BP
ACE inhibitors (captopril) - inhibit RAAS system
94
common withdrawal syndromes
1. alcohol
2. benzos
1. tremors, agitation, anxiety, delirium psychosis
2. tremors, anxiety, perceptual disturbances, psychosis, insomnia
95
common withdrawal syndromes
1. opioids
1. N/V, abd cramping, diarrhea, muscle aches
96
common withdrawal syndromes
1. stimulants
1. increased appetite, hypersomnia, intense psychomotor retardation, severe depression (crash)
97
Bronchiectasis
1. pathophysiology
2. clinical features
1. airway insult (e.g. infection, inhalation) with impaired clearance (e.g. mucostasis, immunodeficiency) - vicious cycles of infection and inflammation resulting in airway dilation
2. daily production of thick +/- blood tinged mucus. Acute exacerbations include recurrent infections with mucopurulent sputum +/- frank hemoptysis
98
How does positive pressure ventilation (PPV) help as treatment for acute cardiogenic pulmonary edema
1. Directly raises the intrathoracic pressure causing a drop in venous return to the right heart (decreases right ventricular preload)
2. elevated intrathoracic pressure compresses alveolar capillaries, raising pulmonary vascular resistance, increases RV afterload
---> 1 and 2 cause less blood volume returning to the left atrium (less LV preload) -- this helps promote more efficient systolic ejection
PPV also decreases LV afterload
99
Hypercapnia causes
1. (BLANK) in brain
2. (BLANK) in lungs
1. vasodilation in brain
2. vasoconstriction in lungs
---with vasoconstriction in lung bases and dead space in lung apices this leads to hypercapnia --- supplemental O2 should be titrated to goal of 88-92 or else you will get neurologic dysfunction (encephalopathy)
100
In the presence of a penetrating injury signs such as (BLANK) are predictive of need for urgent surgical repair --4
1. observed pulsatile bleeding
2. presence of a bruit or thrill over the injury
3. expanding hematoma
4. signs of distal ischemia (e.g. absent pulses, cool extremities)
101
Patients with cocaine-associated chest pain should be treated initially with (BLANK)
IV benzodiazepines - improves psychomotor agitation, myocardial oxygen demand, and alleviate cardiovascular symptoms
102
What cardiac rhythm/situation should defibrillation shock be given?
Ventricular fibrillation
PULSELESS ventricular tachycardia
-- then can follow with CPR
---ventricular "stuff" -- go to defibrilator
103
What cardiac rhythm/situation should defibrillation shock NOT be given and go straight to CPR?
PULSELESS electrical activity or asystole
104
what murmur is heard with marfan syndrome --> aneurysmal aortic root dilation
aortic root dilation can lead to chronic aortic regurgitation
-- early decrescendo diastolic murmur best heard at right upper sternal border
If left untreated can lead to type A aortic dissection
105
ST elevation in leads II, III, and aVF indicate MI in (BLANK artery) which commonly involves (BLANK ventricle)
1. RCA
2. Right ventricle
106
Pyschogenic pseudosyncope (PPS) is a type of conversion disorder rather than syncope
1. what is it?
2. what 3 main features?
1. apparent, transient LOC without impaired cerebral perfusion
2. Prolonged LOC (e.g. 20 min)
- Absence of objective findings like abnormal vitals, pallor, sweating
- patient reports symptoms/events that occured during the episode
107
Pulse <50/min and symptoms present
+ hemodynamically unstable
what should be treatment of symptomatic bradycardia
atropine 1 mg IV - reduces parasympathetic activity
108
MOA of adenosine
transient block of conduction at the AV node - which is useful when identifying (and sometimes terminating) supraventricular tachycardia
109
patients with persistent tachyarrhythmia (narrow or wide complex) causing hemodynamic instability with a pulse should undergo (BLANK)
Synchronized cardioversion
110
What therapy is important part of acute medical management of acute coronary syndrome?
dual antiplatelet therapy with aspirin and P2Y12
111
acute liver failure
1. diagnostic requirements (ALT, AST, symptoms)
1. ALT and AST often >1,000
2. Signs of hepatic encephalopathy (e.g. confusion, asterixis)
3. synthetic liver dysfunction (INR >= 1.5)
112
What imaging is gold standard for malrotation with midgust volvulus?
Upper GI series - shows right sided ligament of Treitz and a corkscrew duodenum
113
BP greater than 180/120 mmHg with evidence of end organ damage
--- In the instance that heart failure and pulmonary edema is the end organ damage what can be done to help
Nitroglycerin can vasodilate and lower afterload pressure to allow heart to pump more efficiently
114
Why would bicarbonate be decreased in DKA?
Because buildup of acidic molecules consume bicarbonate for neutralization
115
treatment of severe hypoglycemia in a diabetic patient requires administration of either (blank) or (blank)
carbs or glucagon
- pt without IV access can get IM glucagon to reverse hypoglycemia
116
Tension pneumonthorax
1. steps to treatment
1. needle thoracostomy to relieve pressure off of mediastinal organs (heart)
2. but then needs to be followed by tube thoracostomy to allow lung expansion
117
Thyroid storm is a serious potential complication of hyperthyroidism
1. signs and symptoms?
2. Diagnosis starts with
1. Hyperthermia, tachycardia, tachypnea, hypertension, diaphoresis, agitation, tremor, hyperreflexia, nausea, and diarrhea and may progress to high output heart failure
2. Thyroid function testing
3. thyroid storm rapid treatment should include beta blockers, hyperthermia treated with antipyretics and cooling
118
Initial treatment of acute cholecystitis before surgery is done?
supportive therapy, IV fluids, IV antibiotics (pip tazo)
119
Treatment for
1. non-displaced scaphoid fractures
2. displaced scaphoid fractures
1. thumb spica splinting
2. Surgical repair
120
Needlestick injuries
1. If patient has not received Hep B vaccine series what should be done?
2. Unsure about his tetanus shot
3. Tetanus shot for clean/small wounds vs other wounds
1. Give Hep B vaccination + HBIG
2. give tetanus booster
3. Clean/small wounds and pt hasn't had tetanus 10+ years then give tetanus shot
--> In all other wounds it is 5+ years from last tetanus shot
121
Epigastric abdominal pain that radiates to the back along with nausea and emesis - often patient history includes gallstones, alcoholism, trauma, hypertriglyceridemia, or hypercalcemia
what is this?
acute pancreatitis - increased lipase
122
ST elevation in V2 through V6 indicates injury to the myocardial territory supplied by the (BLANK) artery
left anterior descending coronary artery - includes anterior portion of interventricular septum, anterior left ventricle, and anterolateral papillary muscle
123
Lateral leads =
Inferior leads =
Anterior/septal leads =
* name the leads and the arteries for each
1. I, aVL, V5-V6 --> Left circumflex or diagonal of LAD (left anterior descending)
2. II, III, aVF --> RCA and/or Left circumflex
3. V1-V4 --> Left anterior descending
124
What is unstable angina and NSTEMI treated with?
Dual antiplatelet therapy (platelet and P2Y12 inhibitor like clopidogrel, ticagrelor)
+
full dose of anticoagulant (like heparin --dabigatran, rivaroxaban, apixaban, and edoxaban)
--- patients are then risk stratified to determine urgency of cardiac catheterization
