EM EOR Topic List_GI_Ortho/Rheum Flashcards
(SmartyPance)
how do we diagnose acute appendicitis?
clinically -
(remember Rovsing sign, Obturator sign, psoas sign)
if presentation is atypical - apply u/s or CT abd
CBC - neutrophilia support dx
(SmartyPance)
what is treatment for acute appendicitis?
surgery
(SmartyPance)
how do we diagnose giardiasis?
giardiasis: stool sample, search for cysts or trophozoites
(SmartyPance)
how do we diagnose pinworm?
scotch tape test (in early morning)
- look at eggs under microscope
(SmartyPance)
how do we diagnose tapeworm?
tape test for diphyllobothrium latum
stool sample for eggs
(SmartyPance)
how do we diagnose hookworm?
test stool sample for adult worms
(SmartyPance)
how do we diagnose roundworms?
stool sample for eggs or adult worms
(SmartyPance)
how do we diagnose amebiasis?
stool sample for trophozoites
(SmartyPance)how do we treat giardiasis?
tinidazole = first line treatment
metronidazole 250 - 750 PO TID
symptoms resolve w/in 5-7 days
(SmartyPance)
how do we treat for pinworms?
mebendazole
or
pyrantel pamoate
(SmartyPance)
how do we treat hookworm?
mebendazole
or
pyrantel
(SmartyPance)
how do we treat roundworm?
albendazole
mebendazole
pyrantel pamoate
(SmartyPance)
how do we treat amebiasis
iodoquinol
or
paramomycin and metronidazole for liver abscess
(SmartyPance)
how do we diagnose acute cholecystitis?
U/S
HIDA (gold std) - when u/s is inconclusive CT scan (alternative, more sensitive for perf, abscess, pancreatitis)
LABS: alk phos, GGT (gamma-glutamyl transferase), conj bilirubin
(SmartyPance)
how do we diagnose choledocholithiasis
gold std = ERCP
(SmartyPance)
how do we treat acute cholecystitis?
cholecystectomy (first 24-48 hours)
(PPP)
how do we treat diarrhea (4 things)?
four parts:
1 - fluid (this is a mainstay of management, oral is best!)
2 - diet (low-residue, bland)
3 - anti-motility agents
(do NOT give these to pts w/ invasive diarrhea)
4 - antiemetics
(PPP)
how do we treat constipation?
four possibilities:
fiber
bulk-forming laxatives (psyllium, methylcellulose)
osmotic laxatives (PEG, lactulose, sorbitol, magnesia)
stimulant laxatives (bisacodyl, senna)
(PPP)
how do we define constipation?
less than 2-3 bowel movements/week
(remember ROME III criteria? need two of them
(SmartyPance)
how do we diagnose heartburn?
Diagnosis: Patients with self-limiting or mild symptoms do not automatically require further workup
(SmartyPance)
how do we diagnose those with atypical or long-standing heartburn symptoms?
diagnostic testing to confirm the diagnosis and to rule out complications of GERD
(??? this is a lame question - research it and improve it!)
(PPP)
how do we diagnose GERD?
clinically, based on hx
or
24-ambulatory pH monitoring (this is the gold std if confirmation is needed)
you CAN do esophageal manometry as well, check for decreased LES pressure
(PPP)
how do we diagnose GERD with persistent symptoms or alarm symptoms?
endoscopy - first line diagnostic test if persistent symptoms or complications of GERD is suspected
(i.e. alarm symptoms, malignancy, symptoms >5-10 years)
(PPP)
how do we treat GERD?
lifestyle modifications
- lift head of bed - don't eat right before bed - avoid foods that delay gastric emptying - stop smoking and drinking - lose wt
“Stage 2”: antacids and H2 receptor antagonists
“Stage 3”: PPI in moderated to severe disease
med-refractory? time to talk about sx (Nissen)
(SmartyPance)
List the four biliary and five hepatic causes of RUQ abdominal pain
BILIARY: 1 - biliary colic 2 - cholecystitis (acute) 3 - cholangitis (acute) 4 - sphincter of Oddi dysfunction HEPATIC: 1 - hepatitis (acute) 2 - perihepatitis 3 - liver abscess 4 - Budd-Chiari syndrome 5 - portal vein thrombosis
(SmartyPance)
list the four causes of LUQ abdominal pain
splenomegaly
splenic infarct
splenic abscess
splenic rupture
(SmartyPance)
list seven causes for acute hepatitis
1 - VIRAL HEPATITIDES (HAV, HBV, HCV 2 - parasites 3 - ETOH 4 - drug-induced (acetaminophen) 5 - autoimmune hepatitis 6 - steatohepatitis 7 - metabolic disease
(SmartyPance)
two common characteristics of acute hepatitis
RECENT TRAVEL
SUDDEN JAUNDICE
(SmartyPance)
what is the initial prodrome of acute hepatitis?
FLU-LIKE SYMPTOMS (fatigue, nausea, vomiting, HA)
followed by
JAUNDICE (1-2 weeks after)
(SmartyPance)
list the later symptoms of acute hepatitis
RUQ pain jaundice scleral icterus hepatomegaly splenomegaly fever
(SmartyPance)
what is a good initial imaging modality to r/o other causes of abd pain (in terms of hepatitis)?
ULTRASOUND
(SmartyPance)
what are the two ultrasound signs of hepatitis?
HEPATOMEGALY (most sensitive sign) and
GALLBLADDER WALL THICKENING
(SmartyPance)
what may show up in the CBC for a pt with hepatitis?
ELEVATED WBC COUNT
(SmartyPance)
what do we usually find on the hepatic panel when suspecting hepatitis?
- HYPERBILIRUBINEMIA (mixed direct and indirect)
- AST and ALT dramatically elevated
- ALT higher than AST
(SmartyPance)
when working up a hepatitis diagnosis, what do we consider if AST:ALT is > 2?
ALCOHOLIC HEPATITIS
if AST:ALT > 2, suspect alcoholic hepatitis
(SmartyPance)
what do we do we do for treatment of severe acute hepatitis B?
antiviral therapy (nucleoside analogs (i.e. entecavir)), pentoxifylline and/or corticosteroids
(SmartyPance)
What do positive IgM HAV Ab indicate?
Acute Hep A
(SmartyPance)
what do positive IgG HAV Ab indicate?
a past exposure
(SmartyPance)
what are the GET SMASHHED common reasons for pancreatitis?
Gallstones
Ethanol
Trauma
Steroids Mumps Autoimmune disease Scorpion sting Hypercalcemia Hyperlipidemia ERCP Drugs
(SmartyPance)
how do we make diagnosis of pancreatitis?
clinical +
LIPASE, elevated +
AMYLASE, elevated
(SmartyPance)
what is the diagnostic test of choice for suspected pancreatitis?
abdominal CT
(SmartyPance)
what is the most sensitive test for diagnosis of chronic pancreatitis?
ERCP is the most sensitive for chronic pancreatitis
RR: “chronic pancreatitis is largely a clinical diagnosis b/c imaging and lab studies are commonly ambiguous”
(SmartyPance)
what are two ugly bruising signs of pancreatitis?
Grey Turner's sign (flank bruising) or Cullen's sign (bruising near umbilicus)
(SmartyPance)
what is the treatment for pancreatitis?
IV Fluids (fluids, fluids, fluids!)
analgesics
bowel rest
(SmartyPance)
what is a complication of pancreatitis?
PANCREATIC PSEUDOCYST
a circumscribed collection of fluid rich in pancreatic enzymes, blood, and necrotic tissue
(SmartyPance)
what is the difference between anorectal abscess and fistula?
anorectal abscess is a result of infection, whereas
fistula is a chronic complication of an abscess
(SmartyPance)
how do we treat anorectal abscess?
SURGICAL DRAINAGE followed by: cleaning analgesics STOOL SOFTENERS HIGH-FIBER DIET
(SmartyPance)
what do we need for high-risk anorectal abscess patients, in addition to surgical drainage?
antibiotics
(SmartyPance)
what is an open tract between two epithelium-lined areas and is associated with deeper anorectal abscesses?
anorectal fistula
(SmartyPance)
how do we treat anorectal fistula?
SURGICALLY
(SmartyPance)
tearing rectal pain and bleeding which occurs with or shortly after defecation, bright red blood on toilet paper
ANAL FISSURE
(SmartyPance)
how do we treat anal fissures?
SITZ BATHS increase dietary fiber increase water intake stool softeners laxatives
(SmartyPance)
how long does it take anal fissures to heal?
HEAL IN ABOUT SIX WEEKS
(SmartyPance)
what do we do if conservative treatment fails for anal fissure?
botulinum toxin A injection
antiemetics
ondansetron (Zofran)
prochlorperazine (Compazine)
metoclopramide (Reglan)
promethazine (Phenergan) (PR, IM, PO), not IV much anymore)
(RR)
“what is the most common cause of small bowel obstruction?
adhesions from prior surgery
(RR)
pt has a fibular head fracture - what finding is most likely seen with
neurovascular exam?
decreased sensation b/w 1st and 2nd toe
(RR)
path of common peroneal nerve
AROUND THE FIBULAR HEAD prior to bifurcating into superficial and deep peroneal nerves
(susceptible to injury here from fibular head fractures as well as from excess pressure with casting or during surgery)
(RR)
what does the deep peroneal nerve do?
PROVIDES SENSATION B/W 1ST AND 2ND TOE
MOTOR FXN TO TIBIALIS ANTERIOR (dorsiflexion and inversion of ankle)
MOTOR FXN TO EXTENSOR HALLUCIS LONGUS (extension of great toe)
(RR)
“A 57-year-old man presents with low back pain radiating down his right lower extremity. On PE, he has decreased sensation in the L5 distribution. What is the most likely cause of his symptoms?”
REPETITIVE FLEXION
(RR)
the most common cause of radiculopathy
disk herniation
(RR)
where are the majority of disk herniations, and why?
L4/5 and L5/S1
THESE SPINAL LEVELS ARE MOST SUSCEPTIBLE TO HERNIATION FROM REPETITIVE FLEXION OF THE TORSO
(RR)
“what is the difference b/w a herniated vs a bulging disk?”
herniated disk - rupture of nucleus pulposus beyond annulus fibrosus of vertebral body
(RR)
three PE findings for herniated disk pulposus
POSITIVE STRAIGHT LEG RAISE
tenderness in sciatic notch
limited ROM
(diagnosis is made by MRI)
(RR)
acutely hot, swollen, tender joint is considered ___________ until proven otherwise.
BACTERIAL SEPTIC ARTHRITIS
(RR)
three most common features of septic arthritis
1 - joint pain
2 - joint swelling
3 - fever
(RR)
what should you see with WBC count in a pt with septic arthritis?
synovial fluid WBC count > 50,000 WBCs/microL
with a PREDOMINANCE OF NEUTROPHILS
(RR)
how do we treat septic arthritis?
IV antibiotics directed at covering staph and strep
(RR)
MC cause of septic arthritis, overall, and for pts < 35 y/o
Overall: S. Aureus
Age < 35 yrs: N. gonorrhea
(RR)
what are the 6 P’s of compartment syndrome?
parasthesia paralysis pallor pain out of proportion to exam pulselessness poikilothermia
(RR)
what positive physical exam finding is most consistent with supraspinatus tendonitis?
Hawkins-Kennedy test (or Neer test)
(RR)
treatment for rotator cuff tendinopathy
ice
rest
NSAIDs
(RR) "Which of the following is more common in ulcerative colitis than in Crohn disease? a) development of malignancy b) fissures c) intestinal obstruction d) small intestine involvement"
“A) DEVELOPMENT OF MALIGNANCY”
(PPP 170)
how do we diagnose Crohn Disease?
INITIAL TEST OF CHOICE: UPPER GI SERIES - STRING SIGN
endoscopy - segmental “skip areas”
biopsy - transmural inflammation, noncaseating granulomas
(PPP 170)
How does Crohn Disease present itself?
ileocolitis:
- crampy abd pain, esp RLQ
- DIARRHEA (not usually grossly bloody)
- WEIGHT LOSS
- fever
(PPP 171)
what is the common clinical manifestation of Ulcerative Colitis?
DIARRHEA (often BLOODY)
CRAMPY ABDOMINAL PAIN, esp LLQ
TENESMUS
(PPP 171)
how do we diagnose Ulcerative Colitis (3 things)?
flexible sigmoidoscopy might show us UNIFORM ERYTHEMA AND ULCERATION
barium enema: STOVEPIPE OR LEAD PIPE SIGN
labs: POSITIVE P-ANCA (perinuclear anti-neutrophil cytoplasm antibodies)
(RR)
treatment for Ulcerative Colitis?
sulfasalazine
surgery is curative
(RR)
two complications of ulcerative colitis
toxic megacolon
INCREASED COLON CANCER RISK
(RR)
findings of Ulcerative Colitis?
CONTINUOUS mucosal inflammation, ALWAYS INVOLVING THE RECTUM
SmartyPance: “isolated to the colon, starts at the rectum and move proximally”
(RR)
“is a large amount of diarrhea more common in ulcerative colitis or Crohn Disease?
ULCERATIVE COLITIS
(RR)
what are two findings upon CT that are apparent with acute cholecystitis cholelithiasis?
thickened gallbladder wall GREATER THAN 4-5 mm
PERICHOLECYSTIC FLUID
(RR)
“fever, RUQ pain, and jaundice suggest what pathology?”
“ASCENDING CHOLANGITIS”
(RR)
signs of strangulated hernia
severe pain peritonitis symptoms of bowel obstruction overlying skin changes elevated WBC or serum lactate
(RR)
a pt w/ an exam indicative of strangulated hernia should receive……what…?
cefoxitin IV
emergent surgical consultation
(RR)
what should you never do with a strangulated hernia?
reduce it in the ER
(this could introduce ischemic bowel into the peritoneal cavity, leading to translocation of bowel flora and abd infection or sepsis)
(RR) inguinal hernias -
indirect vs direct - where are they located?
indirect: LATERAL TO THE EPIGASTRIC ARTERY through inguinal canal, into scrotum or labia through internal inguinal ring
direct: MEDIAL TO THE EPIGASTRIC ARTERY directly behind superficial inguinal ring, do not extend into scrotum
(RR)
which type of inguinal hernia pass through a patent processus vaginalis in the inguinal ring?
INDIRECT
(RR)
treatment for nondisplaced humerus fracture
immobilization in a sling, one week
f/u PE and imaging one week after injury
(RR)
what is the most commonly affected nerve root in posterolateral disk herniation resulting in cervical radiculopathy
C7
(RR)
what is the result of C7 disk herniation and radiculopathy
pain that radiates down the posterior arm to the dorsum of the forearm and third digit
weakness w/ forearm extension and pronation
and
decreased triceps reflex
(RR)
what antibody test is positive when testing for celiac disease?
transglutaminase antibody test
(RR)
what is a strange direct manifestation of celiac disease that causes vesicobullous pruritic lesions on the elbows, knees, and buttocks?
DERMATITIS HERPETIFORMIS
(RR)
what happens to Vitamin K as a result of celiac disease?
decreased Vitamin K absorption –> inhibition of clotting cascade –> increase in prothrombin time
(RR)
what is the treatment regimen of choice for hepatic encephalopathy?
LACTULOSE AND RIFAXIMIN
lactulose decreases absorption of ammonia and alters colonic pH to trap ammonia as ammonium in stool
Rifaximin is an oral antimicrobial agent that reduce ammonia-producing enteric bacteria.
(RR)
a lady inverted her ankle stepping off a curb, and she can still walk on it. She has tenderness to palpation of R lateral malleolus. Pain worsens with ankle inversion; there are no bony deformities. What is the most likely diagnosis?
lateral ankle sprain
(RR)
MC injured structure with ankle sprain
anterior talofibular ligament
(RR)
“what are the structures injured in lateral ankle sprain?” (there are 3)
anterior talofibular ligament
calcaneofibular ligament
posterior talofibular ligament
(RR)
how do we treat ankle sprain?
RICE
rest
ice
compression
elevation
(RR)
how is diagnosis of C. dif colitis made?
“diagnosis is made by nucleic acid amplification test (NAAT)”
(RR)
how do we treat C.diff colitis in adults?
nonsevere or severe: ORAL VANCOMYCIN or oral fidaxomicin
(RR)
what might you see on a CXR of a perforated gastric ulcer?
free air under the diaphragm
(RR)
what is the treatment for peptic ulcer disease which is positive for H. pyrlori infection?
triple therapy:
PPI
clarithromycin, and
amoxicillin or metronidazole
(RR)
what is the most common cause of upper GI bleed?
peptic ulcer disease
(RR) BUZZWORDS
Saturday Night Palsy
radial nerve palsy
(RR)
what findings of lumbar puncture indicate Guillain-Barre syndrome?
markedly elevated CSF protein with mild pleocytosis
Google says pleocytosis is Greek for “more cells”
(RR)
what is the management of patellar dislocation?
CLOSED REDUCTION
(RR)
Charcot triad for acute cholangitis
fever
abdominal pain
JAUNDICE
(RR)
Reynolds pentad for acute cholangitis
fever abdominal pain JAUNDICE \+ confusion hypOtension (i.e. signs of sepsis)
(RR)
in addition to antibiotics (like piperacillin-tazobactam and other broad spectrum abx), what is the treatment of choice for cholangitis?
ERCP
(RR)
pts who are high risk for spinal epidural abscess
IV drug users
alcoholics
immunocompromised pts (i.e. hx of DM)
(RR)
presentation of pts with spinal epidural abscess
lower back pain
TENDERNESS WITH PERCUSSION OF SPINAL PROCESSES
fever - 50% of the time
focal neurologic deficits - 50% of pts
(RR)
modality of choice for diagnosing spinal abscess
EMERGENT MRI
(RR)
what do labs show with spinal abscess?
elevated ESR/CRP (almost always!)
(RR)
how do we diagnose sigmoid volvulus
plain film (low specificity) may show U-shaped, bent inner tube shape
abd CT scan
contrast enema will show the bird beak sign
(RR)
how do we manage sigmoid volvulus?
flexible sigmoidoscopy to reduce volvulus
surgery to prevent recurrence
(RR)
which space or bursa communicates with the knee joint?
the SUPRAPATELLAR BURSA
“the suprapatellar bursa, the largest of the bursae, is not a true bursa but rather an extension of the knee joint capsule.”
this is a good spot for an effusion
(RR)
treatment for acute gouty arthritis
NSAIDs
colchicine
oral glucocorticoids
(RR)
what are the crystals like for GOUT?
NEGATIVE BIREFRIGENT NEEDLE-SHAPED CRYSTALS
(RR)
Lisfranc injury
present with severe pain in midfoot, inability to bear wt, ECCHYMOSIS ON PLANTAR SURFACE OF FOOT
uncommon, usually come from MVCs
articulations of bases of 1st three metatarsals don’t line up with the cuneiforms, they’re all dislocated laterally
(RR)
what exam maneuvers have the highest sensitivity and specificity for sciatica, respectively?
STRAIGHT LEG RIASE
CROSSED STRAIGHT LEG RAISE (passively elevating extended unaffected leg)
