EM Pre-Test Flashcards
1
Q
Think of this when a pt presents with dyspnea with a hx of long bone fracture, major trauma, or ortho procedure?
A
Fat embolism - unlike thromboemboli, these can pass into arterial circulation
Trmt = supportive in ICU
2
Q
COPD is divided into emphysema and what two other categories? Trmt for emphysema?
A
Asthma and chronic bronchitis.
Trmt of emphysema exacerbations = corticosteroids, anticholinergics, and intermittent B2-agonists to decrease inflammation, decrease mucous production, and relax smooth muscles
3
Q
Most effective study to order when considering rib fracture? Potential respiratory risks 2/2 fracture? MC location of rib fractures?
A
Rib series - danger lies in possible penetration injury
Risk of hypoventilation 2/2 to respiratory splinting - increases risk for PNA and atelectasis. Trmt = pain relief to prevent above - if multiple rib fractures, several intercostal nerve blocks appropriate
MC location = point of impact or posterior angle
4
Q
What physical complaint involving extremities can pts with anxiety attacks p/w?
A
Carpal-pedal spasms 2/2 transient decrease of calcium 2/2 respiratory alkalosis (elevated pH causes albumin to become more charged and bind more Ca)
5
Q
What should be given to a pt w/ a recent asthma attack in addition to B2-agonist?
A
3-10 days of prednisone (40 - 60 mg)
6
Q
Trmt for a pt p/w decreased RR, pinpoint pupils (2mm or less) and AMS?
A
Naloxone 2/2 probable opioid intoxication = mu-opioid competitive antagonist
7
Q
Causative agent of pt ℅ initial flu-like symptoms with severe deterioration in 1-2 days: septic shock, respiratory failure, and mediastinitis, widened mediastinum w/ h/o sheep/cattle/horse exposure
A
B Anthracis
8
Q
Causes of exudative vs. transudative effusions?
A
Exudative: malignancy, infection, connective tissue disease, PE, trauma, uremia, pancreatitis, post-surgical, esophageal rupture, drug-induced
Transudative: CHF, hypoalbuminemia, cirrhosis, myxedema, nephrotic syndrome, SVC syndrome, peritoneal dialysis
9
Q
Labs and their respective cut off points for deciphering transudative v. exudative effusions?
A
LDH: > 200 (or LDH ratio > 0.6)
Protein: ratio > 0.5
Also - amylase, cell count, gram stain, cytology, glucose
10
Q
When to give steroids before PCP antibiotic trmt? And why?
A
Give steroids if PO2 < 70 or A-a gradient > 35mmHg. Abx use causes organism death with subsequent inflammation - if no pretreatment w/ steroids in above settings, inflammatory response could precipitate worsening respiratory symptoms
11
Q
What can you use to monitor asthmatic’s response to trmt?
A
Peak Expiratory Flow (FEV1). Asthma triggers = dust, perfumes, exercise, menstruation, smoking, aspirin, infections, etc.
12
Q
How does cholinergic crisis present? Trmt? MCC via toxicity routes?
A
SLUDGE = Salivation, Lacrimation, Urination, Defecation, GI problems, Emesis and Miosis (small pupils). Commonly contained in insecticides = organophosphates = Anticholinesterase inhibitors = cholinergic crisis! Treat with Atropine (anti-cholinergic) and Pralidoxime (restores Anticholinesterases)
13
Q
What helps distinguish GHB toxicity?
A
LOC fluctuates b/w periods of respiratory arrest w/ apnea and periods of combative behavior after noxious stimuli
14
Q
What clues you into CO toxicity? Order what test? Trmt?
A
Flu-like illness (normally w/o high fever), MC in winter months (2/2 heaters, etc), entire family is symptomatic and improves while away from source. Order carboxyhemoglobin levels (NL = 0-5%). Give O2 unless CO level >25%, then hyperbaric therapy
15
Q
Trmt for acetaminophen (tylenol) toxicity? Possible damage to…?
A
N-acetylcysteine reduces risk of hepatotoxicity
16
Q
Anticholinergic presentation? Trmt? Key to distinguishing from sympathomimetic syndrome?
A
“Blind as a bat (mydriasis), red as a beet (flushed), hot as a hare (hyperthermia), dry as a bone (dry membranes), and mad as a hatter (AMS)”. Phyostigmine = reversible cholinesterase inhibitor. Sympathomimetic syndrome = diaphoretic
17
Q
Heroine (opioid) intox presentation and trmt? Trmt for BDZ overdose?
A
Low respiratory effort, miotic pupils, and CNS depression. Naloxone should be administered after attention is given to airway management. Give Flumazenil for BZD overdose.
18
Q
What substance can cause seizure activity refractory to standard rx protocol (which is???)? What’s the trmt? Beware of???
A
Isoniazid. Std = diazepam (BZD), phenobarbital, and phenytoin. Pyridoxine (B6) = trmt. Look out for acidosis and respiratory compromise.
19
Q
What type of diabetes medication can cause recurrent episodes of hypoglycemia?
A
Glyburide = common Sulfonylurea. Insulin is the MCC of iatrogenic episodes of hypoglycemia but patients recover after dextrose or a meal unlike glyburide where recurrent episodes are seen despite above therapy.
20
Q
Aspirin toxicity presentation? Vs. Pseudoephedrine or diphenhydramine?
A
Tinnitus, hyperthermia, diaphoresis, confusion, N/V. Commonly see metabolic acidosis with anion gap and respiratory alkalosis
Benadryl = decongestant having anticholinergic properties and anti-histaminic properties (may cause sedation)
Pseudoephedrine = stimulation, tachycardia, dysrhythmia, hypertension
21
Q
Serotonin syndrome presentation?
A
Diaphoresis, tachycardic, fever, agitation, tremor, myoclonus, ataxia, sometimes diarrhea, hyperreflexia, and shivering. Difficult to distinguish b/w sympathomimetic syn so med hx will help
22
Q
What things can’t charcoal NOT bind?
A
Lithium (needs to be dialyzed), hydrocarbons, metals (Fe), ethanol, and ions
23
Q
Trmt for cocaine intox?
A
BZD’s (ie: Diazepam)
24
Q
What is happening with a pt with known drug abuse who is yawning, has rhinorrhea, piloerection, N/V/D, hyperactive bowel sounds, diaphoretic, anxiety, fear and tachycardia?
A
Opioid withdrawal
25
Wthdrawal of _____ leads to tachycardia, autonomic hyperactivity, tremors, HTN, hyperreflexia? Life threatening?
Ethanol - yes.
26
Withdrawal from ____ leads to HA, flushing, sweating, hallucinations, anxiety, and reflex tachycardia?
Clonidine
27
Hallmark of PCP intox? Typical neuro findings? Trmt?
Recurring delusion of superhuman strength and invulnerability. Nystagmus (vertical/horizontal/rotary). Trmt = conservative, sometimes antipsychotics or BZD's are used for sedation purposes.
28
How to calculate Anion Gap? NL: gap? Causes of increased anion gap?
[Na+] - [Cl- & HCO3-]. NL = 6-12.
MUDPILES = methanol/metformin, uremia, DKA, paraldehyde (anticonvulsant/sedative). Iron/INH, lactate, ethylene glycol, ethanol, salicylate
29
How to calc serum osmolarity? NL level? Common causes of increased osmolar gap? Differentiating them?
[2xNa+] + [Glucose/18] + BUN/1.8 + EtOH/4.6. Gap > 50 = osmolar gap typical of alcohol intox but 10-15 = NL.
"MAE DIE" = Methanol, Acetone, Ethanol, Diuretics (mannitol/sorbitol), Isopropyl Alcohol, Ethylene Glycol
Methanol (wood alcohol forms formic acid) usually has hallucinations in presentation. Isopropyl (rubbing alcohol becomes acetone) has no anion gap met acidosis seen. Ethylene Glycol (antifreeze becoming oxalic acid) causes Calcium Oxylate kidney stones
30
TCA toxicity p/w? Trmt?
Widened QRS (2/2 Na blocking), dysrhythmias. Greater risk of toxicity b/c anticholinergic effects of TCA causes absorption to slow. Can give activated charcoal for this! Sodium bicarb also administered until QRS = 7.55
31
How does NAC work?
It's a glutathione precursor to reduce NAPQI, the toxic metabolite of acetaminophen.
32
Why does ethylene glycol cause problems? Trmt?
Metabolized to glycol acid, making an anion gap metabolic acidosis, and further metabolized into oxalic acid. This combines with Ca to form calcium oxalate crystals that precipitate in renal tubules, brain and other tissues. Wood lamp can also show fluorescence of urine. Trmt = Fomepizole
33
Which alcohol is NOT associated with anion gap metabolic acidosis?
Isopropyl alcohol - but it can cause hemorrhagic gastritis. It's "bitter". Remember, "ketosis without acidosis" b/c metabolized to acetone, giving it distinct breath smell.
34
What clue involving PO2 tips you off to Methemoglobinemia?
Normal PO2 but the patient doesn't respond to supplemental O2
35
3 mainstays of Salicylate tox?
1) charcoal to prevent further absorption 2) hydrate 3)sodium bicarb for those with levels > 35 - this helps alkalize the urine to promote excretion. If levels >100, coma, or end-organ failure, then dialysis is key!
36
Side Effect of N-AC?
Anaphylactoid rxns = rash, bronchospasm, hypotension, and death
37
What are some common Hydrocarbons (HC) and what would happen to someone who recently abused them and tried to perform physical activity?
Household polishes, Glues, Paint Remover, Industrial Solvents. Mainly affects lungs, heart, and CNS = crackles/bronchospasm/edem, sensitization of the cardiac cells, and euphoria. Can precipitate sudden cardiac death 2/2 ventricular arrhythmias.
38
Bradycardia + Hypotension in a pt with BP medications has what tox? Trmt?
B-adrenergic blocker (BBlocker). Treat hypotn with fluid resuscitation and atropine. Charcoal to inhibit further absorption. And Glucagon for inotropic and chronotropic effects
39
Effects of MDMA?
MDMA = ecstasy. Restless, ataxic, euphoric. Causes the release of Serotonin and this causes increase in vasopressin (ADH), resulting in increased thirst and hyponatremia. The hyponatremia = hallmark finding.
40
Patients who swallow drugs should receive…?
Charcoal and whole-bowel irrigation
41
What pain killer should be avoided in pts taking MAOI's? Other drugs to avoid?
Meperidine (Demerol). Avoid any TCA or SSRI's but also keep in mind that cocaine, amphetamine, and dextromethorphan can cause indirect increases in serotonin.
42
What helps distinguish a cerebral concussion from a contusion?
A concussion is not seen on imaging; they normally have periods of amnesia and can't recall the incident, +HA, and V but NO prolonged neural deficits; the LOC is due to impairment of RAS. A contusion is normally seen on imaging and results from the brain hitting the skull - this results in prolonged focal neuro deficits
43
Classes of hemorrhage and their findings?
Class I - 0-15%/0-750mL blood loss, mostly asymptomatic, mild tachycardia
Class II - 15-30%/750-1500mL blood loss, tachycardic, tachypnea, mild anxiety, slight decrease in urine production
Class III - 30-40%/1500-2000mL blood loss includes above + AMS and decrease in SBP
Class IV- >40%/>2000mL blood loss includes above + lethargy, little to no urine production
44
Leading cause of death and disability in trauma victims?
Head injury = immediate cause of death (sec-min) > c-spine injury > great vessel injury > obstruction of breathing
45
Where could you identify fluid quickly if suspected intraperitoneal hemorrhage is suspected? Next step?
Morrison's Pouch (b/w R kidney and liver) - only need 70 cc to see fluid. Exploratory laparotomy
46
In a trauma situation (stab/GSW/blunt trauma) with unstable/crashing vitals, what's the next step when you have hypotensive pt with JVD and muffled heart sounds?
Emergency thoracotomy - cardiac tamponade is likely. Pericardiocentesis is not appropriate now because the blood is likely clotted in there pericardium vs. viscous in a stable pt.
47
How would you advise a patient to bring an avulsed tooth to the ED?
If pt can put it back in socket, it's ideal! If not possible: under tongue > milk > saline
48
Top 2 MC'ly injured organs in stabbing? Blunt Trauma?
(Stabbing) Live (size) > small bowel
| (Blunt Trauma) Spleen > Liver > Kidney > SB > Bladder
49
PE signs of PTX? Trmt of stable vs. unstable pt?
Decreased breath sounds over affected lung, and subcutaneous emphysema. Unstable = needle thoracostomy vs. stable pt gets chest tube
50
How does the neurologic exam look in pt with Brown Sequard syndrome?
Ipsilateral motor paralysis and loss of proprioception and vibratory sense; contralateral loss of pain and temperature.
51
Anterior cord syndrome p/w what kind of neurologic exam?
Loss of motor and pain sensation bilaterally below the lesion. hallmark is preservation of vibratory sensation and proprioception because of an intact dorsal column.
52
How many ribs are affected in flail chest? Hallmark sign?
3 adjacent ribs with 2 sites of fracture per rib. Paradoxical breathing = hallmark.
53
Define the anatomical landmarks of the neck and which is most concerning for injury?
Zone I: sternal notch & clavicles to cricoid cartilage
Zone II: cricoid cartilage to angle of mandible
Zone III:angle of mandible to base of skull
Zone II is much more exposed than the others so it's often at higher risk to injury which is why they are most often taken to OR for exploratory sx.
54
Describe the fracture and it's typical cause:
1) Hangman's Fracture
2) Colle's Fracture
3) Boxer's Fracture
4) Jefferson's Fracture
5) Clay Shoveler's Fracture
1) Hyperextension of neck causing bilateral fracture of C2 pedicles (head-on collisions and abrupt decelerations)
2) MC wrist fracture in adults from outstretched falls - dorsally displaced and angulated metaphysics of radius
3) Fracture of the neck of 5th metacarpal from closed fist impact
4) C1 anterior/posterior arch fracture from axial impact on skull (diving)
5) A complete fracture of spinous process in c-spine 2/2 hyperextension
55
Describe 3 types of LeFort Fractures:
I) transverse fracture above the teeth; can move alveolar plate and hard palate
II) apex at bridge of nose and lateral triangulated fractures involving infraorbital ridges with movement of maxilla, nose, and infraorbital rims
III) complete transection running from one zygomatic arch to the other
56
Vascular supply affected by Epidural Hematoma vs. Subdural?
```
Epidural = Middle Meningeal Artery = doesn't cross suture lines
Subdural = Bridging Veins = crosses suture lines
```
57
Describe neuro findings of Central Cord lesion and who's at risk?
Those with DJD and experience hyperextension of the neck can cause ligamentum flavum to cause central cord damage. See loss of rectal tone, loss of upper extremity sensation > lower extremity, and more distal extremities tend to be preserved because of lateralized position in corticothalamic tract.
58
When to give blood in trauma pts? If unable to match, what kind of blood should be given to men vs. women?
Blood products should be administered if vital signs transiently improve or remain unstable despite resuscitation with 2 to 3 L of crystalloid fluid.
Men - Type O Rh +
Women - Type O Rh -
59
Immediate stabilization method of pelvic fractures? Subsequent trmt if unstable?
Pelvic binding garment. Angiography
60
Who should get c-spine radiographs even with no neck pain or limited ROM on PE?
Those > 65 yrs old
61
Pt has _______ if they present with pain with upper ward gaze, hypoesthesia in infraorbital area, intact visual acuity, possible diplopia? What would radiographs show?
Orbital floor fracture. Facial X-ray should show "tear drop" sign into maxilla with air-fluid level; "tear drop" = fat/muscle herniating through orbital floor.
62
Pt has exopthalmost, periorbital ecchymosis/edema, decreased visual acuity, and afferent pupillary defect = ?
Retrobulbar hematoma
63
Trismus (tightening of masseter muscle) could be indicative of what kind of facial fracture?
Zygomatic arch
64
Approach to penetrating abdominal wounds...
```
Stable = FAST or DPL; radiograph to locate trajectory if GSW pt
Unstable = OR for ex lap
```
65
Mgmt of posterior nasal epistaxis?
If elevated INR, give FFP. Silver nitrate is for anterior nasal epistaxis only! Need to use posterior nasal packing, abx, and admit to hospital. (complications = MI, aspiration, card dysrhythmia, CVA)
66
What else should you suspect in near drowning pt? What PE sign would help distinguish c-spine injury?
Possible diving injury. If abdominal breathing is noted without thoracic respirations accompanying them, could mean damage below C3, 4, 5 level (poorly functioning diaphragm 2/2 nerve injury)
67
How do pulmonary contusions present? (PE and radiology)
Clinical manifestations include dyspnea that is usually worsening, tachypnea, cyanosis, tachycardia, hypotension, chest wall bruising, decreasing oxygen saturation, and increasing A-a gradient. Hemoptysis may be present in up
to 50% of cases. Typical radiographic findings begin to appear within minutes of injury and range from patchy, irregular, alveolar infiltrate to frank consolidation.
68
Mgmt of penetrating extremity trauma?
If no signs of distal ischemia (pallor, poikilothermia, pulselessness, pain, paralysis, paresthesia) then angiography can be used for localization purposes. If signs of ischemia - OR!!
69
MC presentation of brain herniation?
Herniated brain causes compression of cranial nerve III leading to anisocoria, ptosis, impaired extraocular movements, and a sluggish pupillary light reflex. As herniation progresses, compression of the ipsilateral oculomotor nerve eventually causes ipsilateral pupillary dilation and nonreactivity.
70
S/p chest tube for hemothorax, indications for thoracotomy are?
1) Initial chest tube drainage of 1000 to 1500 cc of blood
2) 200 cc/h of persistent drainage (c).
3) Patient remains hypotensive despite adequate blood replacement, and
other sites of blood loss have been ruled out.
4) Patient decompensates after initial response to resuscitation.
5) Increasing hemothorax seen on chest x-ray studies.
71
Describe Cauda Equina Syndrome and it's trmt
Leg pain, saddle anesthesia,
and impaired bowel and bladder function (retention or incontinence). Loss of rectal tone and display other motor and sensory losses in the lower extremities. Patients with suspected
cauda equina syndrome require an urgent CT scan or MRI.
72
Acute trmt of elevated ICP?
Hyperventilation to produce an arterial PCO2 of 30 to 35 mm Hg will temporarily reduce
ICP by promoting cerebral vasoconstriction. The onset of action is within 30 seconds. In most patients, hyperventilation lowers the ICP by 25%. Hyperventilation is a
temporary maneuver and should only be used for a brief period of time during the acute resuscitation. Mannitol can be tried after.
73
Hx, PE findings and radiographic findings suggestive of mesenteric ischemia?
Hx = afib
PE = pain out of proportion to exam
Rads = pneumatosis intestinalis or gas in the portal venous system
SURG EMERGENCY!!!
74
MCC of acute episodes of diarrhea? Trmt?
Viral diarrheal diseases = Rotavirus (children), Norwalk virus, Enteric Adenovirus
Trmt = supportive care (hydrate!)
75
MC site of impaction of foreign body in adults?
LES
76
Lab findings in Alcoholic Ketoacidosis? B-OH/AcAc ratio? Trmt?
Anion gap metabolic alkalosis 2/2 V and volume depletion. Beta-hydroxybutyrate/Acetyl Acetate ratio = 5:1
Trmt = hydration with 5% dextrose in NS or 1/2NS. Thiamine can be given as prophylaxis for Wernicke's encephalopathy
77
Test of choice to dx acute cholecystitis?
U/S Imaging - use HIDA if negative U/S in setting of very suspicious hx or equivocal U/S findings
78
Pain med considerations for ureteral stones?
Ketorolac = non-NSAID; possible maintenance with morphine. NSAIDS decrease uterospasm and renal capsular pressure in obstructed kidney
79
Classic triad for ruptured AAA? When to go to OR?
Hypotension, pain, and pulsatile abdominal mass. Go to OR is hemodynamically unstable
80
Lab findings in alcoholic hepatitis? Trmt?
AST > ALT presenting with stigmata of hepatic dysfunction = spider angiomata, gynecomastia, dupotrens contracture.
Trmt = supportive to correct fluid/electrolytes - monitor glucose, Mg, and consider thiamine in chronic alcoholics.
81
Trmt for Spontaneous Bacterial Peritonitis? When to begin trmt? Common causative organisms?
Treat with 3rd generation cephalosporin (cefotaxime) if neutrophil count is > 250. MCC = gram-negative enterococcus (E. Coli/Klebsiella/Strep. Species/Strep PNA)
82
MC times pts p/w testicular torsion?
First year of life and puberty. Order U/S and can attempt manual detorsion with analgesia, followed by surgical intervention if refractory
83
Study findings for + CT in setting of acute appendicitis?
Abd CT with contrast might show: fecolith, pericecal inflammation, or enlarged appendix (>6mm)
84
Triad for cholangitis presentation?
Fever, RUQ pain, jaundice.
85
Diagnostic criteria for pancreatitis?
2/3 of the following: amylase or lipase 3x upper limit, classic abdominal pain, and consistent imaging.
86
Approach to possible ovarian torsion?
If suspicion is high with classic hx, laparoscopy = diagnostic choice b/c diagnostic and therapeutic. If not, U/S is the next best choice.
87
Two possible complications of ERCP?
Pancreatitis or ascending cholangitis
88
Sonographic findings of ascending cholangitis?
Intrahepatic or ductal dilation.
89
Tests for stable AAA?
Evidence of an AAA is seen on plain radiograph approximately 66% to
75% of the time. The most common findings are curvilinear calcification of
the aortic wall or a paravertebral soft tissue mass.
Ultrasound and CT are the best diagnostic tools for the stable patient.
90
Prognostic labs for pancratitis?
LDH, glucose levels, WBC
91
Causative agent for epididymitis for men > 35 and < 35 yo?
> 35 = E. Coli
| < 35 = C. Trachomatis & N. Gonorrhea
92
Trmt for male urethritis?
3rd generation cephalosporin or Cipro for probable gonococal infection + azithromycin or doxycycline or erythromycin for non-gonococcal urethritis (chlamydia)
93
Hx of visit to tropical climate w/ poor sanitation, bloody BM's, RUQ abdominal tenderness, leukocytosis, fever = ? Trmt?
Entamoeba Histolytica - identify pathologic protozoan in stool. Supportive care + metronidazole. Might need to use percutaneous catheritization to drain abscess if refractory.
94
RF's for pyogenic abscess in liver?
MC type of liver abscess. RF's = underlying biliary disease with extra hepatic biliary obstruction leading to ascending cholangitis and abscess formation - associated with choledocholithiasis, benign and malignant tumors, or post-surgical strictures
95
Trmt of acute diverticulitis?
If complicated, admission with antibiotics (anaerobic and gram-neg bacteria). abscess formation >5cm need intervention, <5 can attempt abx alone
96
When to get an US vs. laparoscopy in setting of suspected ectopic?
If the pt is unstable or is showing signs of surgical abdomen, then get laparoscopy instead of US
97
Predictors of mortality in setting of pancreatitis?
```
(Ranson's Criteria):
Age >55
WBC > 16,000
Glucose > 200
LDH > 350
AST > 250
Hematocrit falls > 10% in 48 hrs
BUN rise > 5 (48hrs)
```
98
What radiographs should be ordered in setting of SBO?
Flat and upright abdominal X-rays - flat one shows distended loops and upright illustrates step-ladder progression of air-fluid levels
99
MCC of LBO?
Neoplasm, Diverticulitis, and Sigmoid Volvulus
100
If replacement of a G-tube is needed, how long will the track typically remain patent to allow for replacement?
7-10 days. Water soluble contrast should then be pushed through with a supine abdominal radiograph to ensure proper replacement
101
How often do kidney stones pass on their own depending on size?
< 4 mm = 90% time
4-6 mm = 50% time
> 6 mm = 10% time
102
When should you not try and manually reduce a hernia?
If there is evidence of strangulation (compromised vascular supply) evidenced by erythema
103
What type of hx makes you think of acute mesenteric ischemia?
Pts over 50 with a hx of afib (arterial embolism etiology) or CHF/recent MI/hypovolemia in the setting of non-occulsive etiologies for Acute Mesenteric Ischemia
104
Meds for sexually assaulted victim?
Gonorrhea (Ceftriaxone), Chalmydia (Azithromycin or Doxy), syphilis, and trich (metronidazole). HIV (postexposure prophylaxis with antiretrovirals). Tetanus and Hep B vaccination if update needed.
105
What extra intestinal manifestation is unique to Crohns (not seen in pts with UC)?
Nephrolithiasis b/c of ileal involvement and resultant hyperoxaluria
106
Dx, best test, and MCC of: immunocompromised pt with slowly progressive localized back pain, fever, and progressive weakness?
Epidural abscess. MCC = Stap. Aureus > Gram - bacilli > tuberculosis. MRI
107
MC tumors to met to spine?
"BLT with Kosher Pickles" = breast, lung, thyroid, kidneys, prostate
108
Early Goal Directed Therapy includes 3 basic steps:
For those unresponsive to initial fluid bolus, place central line with broad spectrum abx followed by EGDT:
1) Begin crystalloid therapy or fluid bolus until CVP 8 - 12 mmHg
2) If fluid alone doesn't help, administer vasopressin for MAP > 65 mmHg
3) Check systemic venous O2 saturation; if < 70%, transfuse until HCT = or > 30%…if still low saturation, begin Dobutamine
109
Differentiate SIRS, Sepsis, Severe Sepsis, and Septic Shock
SIRS = (2 or more) RR > 20, HR > 90, T > 100.4, WBC > 12,000 or < 4,000
Sepsis = SIRS + likely/proven infectious source
Severe Sepsis = Sepsis + end organ damage
Septic Shock = Sepsis + Refractory Hypotension
110
Treatment of Epididymitis?
Scrotal elevation, avoiding lifting heavy objects, and abx for infection.
111
PE signs of Fournier's Gangrene and trmt?
PE Signs: crepitus in genital/thigh area, fever, warm/edematous genital area with extreme discoloration. It's a polymicrobial necrotizing fasciitis of perineal subcutaneous tissue originating from skin, urethra, or rectum.
Trmt = widespread abx, surgical debridement, and aggressive fluids.
Complication = necrosis and end-artery thrombosis
112
Labs values for and RF's of septic arthritis? MCC across all age groups?
WBC's > 50,000 or >75% granulocytes. RF's = immunocompromised, previous dx of arthritis, and risky sexual behavior. MCC = staph aureus - give abx before pt leaves!
113
RF's and Trmt for: Fever, hemolytic Anemia, Thrombocytopenia, Renal Failure, and Neuro Changes
" FAT RN" = thrombotic thrombocytopenic purpura
RF= females 10 - 40yrs, pregnancy, malignancy, allogenic bone marrow transplant, medications, autoimmunity (SLE)
Trmt = plasmapharesis - if refractory, corticosteroids and splenectomy
HUS is differentiated by absence of fever and AMS. RF = children with E. Coli or Shigella Dysenteriae
114
Hypotension, fever, diffuse "sun-burn like" rash with subsequent desquamation (esp. on hands/soles) - dx and trmt?
Toxic Shock Syndrome - aggressive fluids, + oxacillin or cefazolin, and admission
115
Name that rash!
1) Develops on palms and soles and rapidly progress to extremities; hiking pt
2) Young child with sore throat and sandpaper rash
3) Neck pain, fever, HA, AMS, with petechial, hemorrhagic vesicles/macules and papules on trunk/extremities
4) Young sexually active adults with pustular and erythematous lesions + arthralgia and fever
1) RMSF - Doxy or Chloramphenicol
2) Scarlett Fever - via S. Pyogenes; trmt w/ Penicillin
3) Meningiococcemia via N. Meningitidis (gram - diplococci) - IV Ceftriaxone
4) Disseminated Gonococcemia - IV Ceftriaxone or Oral Cipro
116
MCC of osteomyelitis?
Staph Aureus > Strep.
117
What is Ludwig Angina? MCC? Preferred method of airway control? Trmt?
Potentially life-threatening inflammation of connectisue tissue of the flow of the mandible MC'ly from tooth extraction. Fever, trismus, bilateral submandibular swelling, and tongue protrusion, subcutaneous emphysema - with NO palpable lymphadenopathy or fluctuance.
Fiberoptic nasotracheal intubation b/c of difficulty with endotracheal or cricothyrotomy (lots of swelling)
Abx: (high-dose pen + metronidazole OR Cefoxitan), Piper/Taz, Clindamycin. Only I/D those with fluctuance or refractory to abx.
118
Acute superficial cellulitis involving dermis, lymphatics, and subcutaneous tissue with SHARPLY demarcated borders = ? Trmt to cover? Associated with?
Erysipella - give abx to cover Group A Strep and Staph. A/w: nephrotic syndrome, small skin breaks, and post-operative wounds
119
Centor criteria?
For Strep Pharyngitis Mgmt:
+1 for Age < 15, pharyngeal exudates, absent cough, anterior cervical lymph, fever by hx. -1 pt for age > 45.
0-1 Pts = no further testing
2-3 Pts = Rapid Test, if Negative, get Throat Culture
4 = Treat
120
Peritonsillar abscess p/w? Trmt?
Sore throat, muffled voice, truisms, fluctuant mass, deviated uvula, odynophagia, and drooling, hx of recent trmt for strep. Trmt = needle aspiration or I/D with abx trmt (consider acuity/stability when deciding method of draining)
121
Mastoid swelling + fever + earache = dx?
Mastoiditis
122
Differentiate epiglotittis and retropharyngeal abscess?
Epiglotittis - F, dys/odynophagia, drooling, dyspnea, inspiratory stridor, thumb-print sign on lateral cervical radiograph VS. prominent cervical lymphadenopathy and possible torticollis seen in retropharyngeal abscess
123
What determines trmt modality of PID?
1) Possible other sx emergency? 2) pregnancy? 3) failure of outpt therapy 4) can't take PO fluids/food 5) TOA
124
RF's and signs of Endocarditis?
RF's: previous hx, IVDU, MVP, prosthetic heart valve, rheumatic/congenital heart disease
PE: Janeway lesions (palmar plaques), Arthritis, Neuro changes, Osler nodes, new heart murmur, retinal hemorrhages, splinter hemorrhages.
125
What pts get amoxacillin instead of doxy with lyme disease?
Kids < 8yo and pregnant/lactating women
126
Stevens-Johnson Syndrome has what type of rash? MCC of M/M? Trmt? Common causes of Syndrome?
Erythema Multiforme involving mucosal membranes. Infection and dehydration. IV fluids, prednisone, analgesics, antihistamines, mouth rinses, and skin care. Infxn (Mycoplasma and HSV), anticonvulsants, antibiotics, and malignancy
127
Common causes of cardiogenic shock?
PE, acute MI, COPD exacerbation, PNA
128
Stable vs. unstable mgmt of SVT?
Narrow complex regular tachycardia. Vagal maneuvers, adenosine (x2), then B-Blockers, CCB's, or Digoxin. If unstable, cardiovert
129
Unstable vs. stable management of VT?
Wide-complex tachycardia. Cardioversion. Stable mgmt = amiodarone (x2 doses) then try lidocaine or procainamide (DONT USE CCB's)
130
Safe endotracheal tube rx's?
Naloxone, Atropine, Versed, Epi. and Lidocaine (use 2-2.5x normal dosage)
131
Trmt of stable vs. unstable Afib?
Crazy p waves with irregularly irregular ventricular depolarization ("RVR"). If unstable, cardiovert. If stable, rate control with diltiazem or verapamil. Metoprolol or digoxin may cause hypotension
132
Atrial flutter trmt?
Low-energy cardioversion
133
What is important to give to pts with hyperkalemia?
Calcium gluconate to stabilize cardiac cell membranes
134
With asystole, what should you do before epi and/or amiodarone trmt?
Check another lead first just in case it fell off or got disconnected
135
What clue can tip you off to neurogenic shock vs. other types?
Other types of shock try to compensate for hypotension with bradycardia. Neurogenic shock is thought to have loss opt sympathetic outflow tracks thus leaving the body unable to use tachycardia as a response to hypotension
136
Trmt for unstable second degree type I (Mobitz) block?
Atropine followed by either transcutaneous pacing or epi/dopamine drip
137
Trmt for Torsades?
Magnesium Sulfate
138
Someone p/w hypotension and long-standing steroid therapy should make you think of?
Adrenal crisis 2/2 to suppressed adrenals - then when faced with stressor (i.e.: infection), it cannot adequately release cortisol or other hormones (would see hyperkalemia and hyponatremia 2/2 to decreased aldosterone)
139
Specific US findings of cardiac tamponade?
Right atrial and ventricular collapse
140
MC injured carpal bone with a fall on outstretched hand?
Scaphoid
141
Characteristics of Pseudogout...
MCC of monoarticular arthritis in the elderly. Deposition from Calcium Pyrophosphate Crystals. Arthrocentesis reveals rhomboid crystals that are positively birefringent (yellow when perpendicular to polarizing light). Supportive trmt with NSAIDS!
142
Thompson test looks for?
Achilles tendon rupture - pt placed in prone position and calf is squeezed; normally this results in plantar flexion, injury would not exhibit this. MRI or U/S if questionable or to confirm
143
Worse place to fracture scaphoid?
Proximally b/c arterial supply begins in distal portion of scaphoid
144
A pt w/ "squared off" shoulder appearance, inability to internally rotate arm, and holding arm abducted and slightly externally rotated clues you into ??? What common nerve is injured? MC fracture associated w/ injury?
Anterior shoulder dislocation with axiallary nerve damage occurring in ~ 1/2 of pts - dysthesias in deltoid region. Compression fracture of the humeral head = Hill-Sachs Deformity
145
Possible hand wounds 2/2 to hitting someone in the mouth should have you consider common pathogens, trmt...
Polymicrobial (Eikenella Corrodens). Get hand radiographs, IV antibiotics (PCN and cephalosporin), keep wound open and splint in functional position
146
Common injury name and trmt for forceful extension of finger?
Mallet Finger or Ruptured Extensor Tendon. Swollen DIP with inability to extend finger, held in flexion b/c unopposed flexor tendons at work. Splint the DIP joint for 6-8 weeks
147
What criteria is used for Tenosynovitis dx and proper trmt?
Kanavel Criteria = (STEP) Symmetric swelling of finger, Tendernes over the flexor tendon sheath, Extension of the digit is painful, and Posture is flexed. Occurs 2/2 to injury and infection of flexor sheath. Immobilize, abx, and surgical consult stat!
148
Name that fracture:
1) Junction of middle 2/3 and distal third of radius + dislocation of the distal radial-ulnar joint
2) transverse fracture of metaphysics of distal radius with ventral displacement and angulation
1) Galeazzi
| 2) Smith (opposite of Colle's)
149
How to measure for compartment syndrome?
Stryker device - pressure > 30 mmHg requires fasciotomy and is diagnostic
150
Posterior shoulder dislocation associated with? P/w? Radiograph sign?
Associated w/ seizures or lightning strikes. Arm is held adducted, internally rotated with limited/no external rotation or abduction. "Light bulb" sign.
Be careful, MOST COMMON dislocation is seizure is still anterior shoulder dislocation, but posterior shoulder dislocation is associated with it.
151
Scaphoid or snuffbox tenderness warrants….
Thumb spica splint and repeat Xray (even if initial negative) in 10-14 days
152
What nerve is at risk from a displaced lunate?
Median nerve - the lunate normally gets compromised in an injury that results in hyperextension of the wrist
153
What do pts ℅ with meniscal tears?
Knee locking or hear a clicking sound with slow growing effusions 6-8 hrs after injury. + McMurray
154
Preserve severed digit?
The best way to preserve an amputated part is to rinse it with normal saline to remove gross contamination, wrap it in sterile gauze moistened with saline or lactated ringers,
and place it in a sterile, water tight container. Then store this container in ice water.
155
Posterior vs. anterior hip dislocation presentation? Possible nerve injury?
Posterior = shortened, internally rotated, flexed, adducted - possible sciatic nerve injury or avascular necrosis of femoral head. 80% of hip dislocations
Anterior = shortened, externally rotated, flexed and abducted.
156
Trmt of high pressure injection injury?
Splint, elevate, abx, tetanus, analgesia, and ortho consult = sx emergency b/c of extensive tissue loss and high infxn rate!
157
What else do you need to assess in person with calcaneal fracture?
Assess for possible dorsolumbar spine. These associated injuries occur 2/2 compression fractures . Minor fractures only require supportive care, immobilization with posterior splint and ortho f/u
158
Common injuries associated w/:
1) Supracondylar Fracture
2) Anterior Elbow Dislocation
3) Humeral Shaft Fracture
4) Olecrannon Fractures
5) Posterior elbow dislocation
1) Brachial artery and median nerve
2) Brachial artery
3) Radial Nerve (wrist drop)
4) Ulnar nerve injury (interossei muscle weakness)
5) Ulnar and median nerve
159
Proximal 1/3 of ulnar shaft fracture with radial head dislocation = dx? Associated nerve injury? Differentiate Night Stick fracture
Monteggia fracture w/ radial nerve injury. Night stick fracture is an isolated fracture in the ulnar shaft
160
What is contraindicated in a pt with Herpetic Whitlow?
I/D 2/2 possible infxn
161
Ottawa ankle/foot rules for radiographs...
Pain in malleolar or mid foot area, bony tenderness at base of fifth metatarsal, unable to bear weight on it for 4 steps immediately after injury or at time of evaluation
162
If wound/laceration has possible FB present, next appropriate test?
Plain film radiography
163
What is considered a contraindication for tetanus vaccination - appropriate trmt? What type of reaction is not?
If pt has cardio or respiratory problems with tetanus vaccine, DON'T USE - instead use Tetanus Immunoglobulin.
Redness, pain, and swelling around the site is NOT an allergic reaction.
164
Type of closure for forehead laceration crossing hairline?
6-0 Nylon. Not staples 2/2 poor cosmesis. Not Dermabond b/c crosses hairline. Not steri strips b/c provides little tension to wound
165
Type of suture material for mucosal laceration?
Absorbable chromic gut = moderate tension, no cosmesis on inner mucosa, and pt doesn't have to return. Not monofilament b/c used for more tensile strength (i.e.: fascia closure)
166
Considerations for how long you leave sutures in?
Balance cosmesis w/ wound closure. Most wounds = 7 days Areas of high tension (arms, hands, legs, feet) need more time 10 days. Sutures on the face = 3-5 days 2/2 cosmesis (don't want hatch marks)
167
Goal for repairing lacerations across vermillion border?
Approximation of vermillion border. Use nerve block and bring edges together first and then work backward - reverse method could potentially make the final line up of the border distorted
168
Deep puncture wounds should be closed how? Abx considerations for dog/cat bites?
Delayed primary closure decreases possible infection or abscess formation.
The most commonly used antibiotic for dog and cat bites is amoxicillin/clavulanate. Clindamycin with a fluoroquinolone can be
used for dog bites in penicillin allergic patients. Doxycycline can be used for cat bites in penicillin allergic patients.
169
Abx trmt for wound with exposure to freshwater?
Covering against gram +, Pseudomonas, and Aeromonas with Fluoroquinolones
170
When to use a mental block?
Pts with lacerations to their lower lip
171
When to use tissue adhesives?
Straight wounds < 5cm in low-tensile areas; can't use on mucosa or hairy parts
172
When would you need a hand surgeon for a chopped distal tip of finger?
If > 10mm, bone is exposed, or nail is injured, consult a hand surgeon. If < 10mm, do not reattach finger tip and simply apply pressure after irrigation
173
Trmt of DKA?
2L fluid bolus + 10 U of insulin bolus followed by insulin drip @ 0.1 U/kg/h
174
Dx and trmt of: hyperthermia, tachycardia, and either CNS, cardiac (high output congestive heart failure or afib), or GI issues diarrhea or pain) in pt with hx of thyroid problem?
Thyroid Storm - treat with propanolol, PTU, and Iodine. These decrease the peripheral adrenergic response, decrease formation of new thyroid hormones w/ mild contribution to inhibition of peripheral conversion of T4 to T3, and blocks further release of hormone from thyroid respectively (Iodine should be given 1hr post PTU to avoid organification)
175
What rx prevents alcohol withdrawl?
Chlordiazepoxide
176
Dx of: generalized edema, hypothermia, bradycardic, AMS (lethargic/coma), dry skin, coarse hair?
Myxedema Coma = severe hypothyroidism
177
Hyperglycemic Hyperosmolar Nonketotic Syndrome p/w? Trmt?
Glucose > 600, plasma osmolarity > 350, dehydration, AMS - NO KETOSIS OR ACIDOSIS! Fluid resuscitation with 2L bolus, 10 U of insulin, and electrolyte depletion.
178
Hypokalemia presents with...
Muscle weakness and flattened T waves or U waves (additional hump following T wave) on ECG
179
Electrolyte and Hx clues for Adrenal Cortical Insufficiency?
Hypoglycemia, Hypotension, Hyponatremia, Hyperkalemia. Trmt = glucocorticoids and electrolyte replacement
180
Describe Neuroleptic Malignant Syndrome and trmt
Reaction to a medication with
dopamine receptor antagonism - neuroleptics,
such as haloperidol, clozapine, and risperidone, lithium and many anti-emetics (prochlorperazine, promethazine, and metoclopramide). The syndrome
presents as fever, altered mental status, and muscular rigidity.
Dantrolene
Vs. Malignant Hyperthermia which results from inhaled anesthetic agents (succinylcholine)
181
What two endocrinologic emergencies can precipitate in the setting of stress like recent infection, MI, stroke, or trauma?
Adrenal Cortical Insufficiency or Thyroid Storm (look at the hx for help!)
182
Describe possible sympt of panic attack:
four or more of the following symptoms develop acutely and peak
within 10 minutes: accelerated HR, palpitations, pounding heart, diaphoresis,
trembling or shaking, sensation of shortness of breath or a choking feeling,
chest pain, nausea, dizziness, lightheadedness, paresthesias, fear of dying, chills,
or hot flushes.
183
What criteria do you use to dx Conversion D/O:
- A symptom is expressed as a change or loss of physical function.
- Recent psychologic stressor or conflict.
- The patient unconsciously produces the symptom.
- The symptom cannot be explained by any known organic etiology.
- The symptom is not limited to pain or sexual dysfunction.
184
Tranylcypromine and Phenelzine = what type of antipsychotic?
MAOI - Avoid Tyramines (red wine, cheese)
185
Time period to diagnose MDD?
Need 2 SIGECAPS symptoms for 2 weeks
186
What to watch out for in the first 5 days of starting steroids?
Steroid psychosis is
described as a constellation of psychiatric symptoms within the first 5 days
of treatment with a corticosteroid.
187
Describe Digoxin Toxicity and Trmt. What meds can increase Dig levels?
Digoxin
directly binds the Na-K ATPase which increases sodium and calcium levels,
increasing the contractility of the heart. Hallucinations are often an early symptom of digoxin overdose.
Treatment for this includes a protein fragment
that binds this medication = Digibind.
"VET PD" = Verapamil / Erythromycin / Tetracyclines / Paroxetine / Diltiazem
188
Best predictors of actual suicide attempt?
Depression or feeling hopeless, organized or serious attempt, and stated future attempt
189
Trmt of widened QRS with TCA-based arrhythmia?
This ECG shows prolonged QRS interval - blocking the reuptake of dopamine, serotonin, and norepinephrine - binds to the γ-aminobutyric acid (GABA) receptor, thereby lowering
seizure threshold. Sodium-channel blockade produces the widened QRS
interval.
Sodium bicarbonate is a first-line intervention for dysrhythmias, acting as alkalizing
binder for the acidic TCA.
If Torsades presents, use magnesium sulfate.
190
Postpartum mood = 3 different types:
1) Postpartum Blues- start right at birth, still care for baby, last up to 2 weeks = no trmt
2) Postpartum Depression - occurs about 1 mo after delivery and thoughts about hurting baby or not wanting it to suffer in the world - trmt = SSRI
3) Postpartum Psychosis - starts anytime and mom has depressive symptoms with psychotic thoughts - remove baby and begin trmt
191
Corneal abrasions should have what type of topical abx coverage?
Anti-pseudomonal coverage = fluoroquinolone or aminoglycoside or tobramycin optho ointment
192
Those with herpes opthalmicus are predisposed to what complications?
Anterior uveitis, secondary glaucoma, and corneal scarring
193
Differentiate Dacrocystitis v. Hordeolum v. Chalazion
1) inflammation of the lacrimal sac
that is characterized by pain, swelling, and erythema of the lacrimal sac on
the extreme nasal aspect of the lower lid. Pressure on the lacrimal sac in a
patient with dacryocystitis may express pus.
2) acute infxn and abscess of glands in eyelids
3) granulomatous inflammations of meibomian glands in the eyelids = hard and NOT tender
194
Reddened conjunctiva and watery discharge, preauricular adenopathy = ? and trmt?
Viral Conjunctivitis. Trmt = cool compresses and antihistamine/a-adrenergic (naphazoline/pheniramine) for symptomatic care.
Bacterial conjunctivits = thick mucopurulent d/cand wake up with their eyes stuck together
195
What's a corneal ulcer look like?
Shaggy white infiltrate
196
Corneal abrasions can be treated with?
Erythromycin ointment
197
Hallmark of corneal epithelial disease caused by HSV? Trmt
Dendritic ulcer. Topical antivirals, trifluridine and antibiotics added to prevent secondary bacterial infxn
198
Subconjunctival hemorrhage trmt?
None - RF's = spontaneous rupture from pressure (cough, bearing down), trauma, htn
199
What's a hyphema?
Hyphema = bleeding into anterior chamber from iris vessel rupture or spontaneous (common in SCD), this can cause elevated IOP
200
How to get glue out of eye area?
Erythromycin ointment can be lubricating and then clumps of glue can be removed manually
201
UV Keratitis trmt?
superficial punctate keratitis
confirms the diagnosis. Treatment consists of analgesia, cycloplegics to reduce
ciliary spasm and pain, erythromycin ointment, and ophthalmology followup
in 1 to 2 days. Fortunately, most patients with ultraviolet keratitis make a
full recovery with supportive care alone.
202
What does flare or floating segments seen on slit-lamp clue you into?
Iritis is diagnosed by history and visualization
of cells and flare in the anterior chamber on slit-lamp examination.
Consistent with an infectious or inflammatory etiology, cells represent leukocytes
floating in the aqueous humor and flare represents a hazy protein accumulation.
203
Orbital Cellulitis p/w and trmt?
Staphylococcus aureus and Haemophilus influenzae
are common etiologies, and mucormycosis must be considered in diabetics and immunocompromised patients.
Distinctive clinical findings of orbital
cellulitis are eye pain, fever, impaired eye motility, decreased visual acuity, and proptosis.
Patients should be treated with IV antibiotics, such as cefuroxime,
a combination of penicillin and nafcillin, or vancomycin and admitted
to the hospital.
RISK = recent URI that extends into orbital septum
204
Dx w/ the aqueous humor production in the posterior chamber of the eye is unable to drain through the anterior chamber and the resultant obstruction causes increased IOP. Increased IOP have a mid-dilated, nonreactive pupil with corneal clouding
and decreased vision.
acute angle-closure glaucoma
205
Afferent pupillary defect can be caused by...
anterior visual pathway of the retina, optic nerve, or optic chiasm preventing
reception of the light in the affected eye
206
Horner Syndrome:
Clinically, patients
| with Horner syndrome have ptosis, miosis, and anhydrosis.
207
Differentiate:
1) central retinal artery occlusion
2) Acute angle closure
3) central retinal vein occlusion
4) Retinal detachment
1) Painless - macular cherry-red spot with a pale retina (a fib) - digital massage, vasodilate, and lower IOP
2) painful - occurs with light change
3) painless - see diffuse retinal hemorrhages on retina from stasis, edema and hemorrhage
4) painless- see floaters or blurry vision curtain followed by painless vision loss
208
Immediate things to do for seizing pt...
Roll on side, O2 admin, pulse ox, glucose level, and IV line
209
Nasal airway should be used in which pts?
Those with intact gag reflex - if no gag reflex, tracheoesophageal airway
210
Why give fluid replacement slowly in HHNS syndrome?
Could cause cerebral edema
211
Trmt for suspected hepatic encephalopathy?
Lactulose and neomycin
212
Phenytoin if administer too quickly can cause what?
Hypotension and cardiac dysrhythmias
213
Cushing reflex? Indicates?
Bradycardia, htn, and decreased RR. Elevated ICP
214
DT's 2/2 alcohol occur?
Can start withdrawing after 6-8 hrs of cessation but DT's MC 3-5 days after
215
What BP goal to use and with what rx for Htn Encephalopathy?
Usually found to be in pts w/ BP > 222/110 - use labetalol or nitroprusside to decrease MAP 20 - 30% (180/100)
216
Bacterial meningitis CSF?
Elevated WBC (>1,000) with >50% PMN's, low glucose (200)
217
Normal CSF?
Protein 40
WBC <5
Cell types - monos
218
Viral Meningitis CSF?
Protein 50-200, Glucose = NL, WBC < 1000, Monos, Neg stain
219
Fungal vs. TB CSF?
Fungal = protein > 200, glucose < 500
TB = protein >200, glucose <1000
POS AFB on stain
220
CSF that reveals blood is suspicious for?
Herpes encephalitis or SAH depending on hx
221
When do you treat hyponatremia?
When symptomatic - normally treat cause, but if having sympts, hypertonic saline (3%) SLOWLY to decrease risk of CPM
222
Normal pressure hydrocephalus = ?
Ataxia, dementia, urinary incontinence
223
Korsakoff vs. Wernickes?
Wernickes= ataxia, opthalmoplegia (nystagmus, gaze palsy), confusion
Korsakoff = above + confabulation and disorientation
224
Crohns characteristics?
Ileal involvement, skip lesions in colon, any GI involvement, rectal sparing, full wall thickness, pathos ulcers, and cobblestone appearance. VS. UC w/ crypt abscesses, epithelial necrosis, and mucosal ulceration. Rectal pain and diarrhea = MC in UC. Continuous lesions at the mucosal level
225
Pain timing w/ gastric vs. duodenal ulcer.
Gastric presents right after eating vs. duodenal = 2-3 hrs after
226
What rx to give to those with portal htn and upper gi bleeding?
Octreotide. PPI if thought to be small
227
Gold std for diagnosis and trmt of acute mesenteric ischemia?
Angiography
228
Test of choice for esophageal perf?
Esophogram with water-soluble agent (Gastrograffin)
229
When to get a CT before LP? Good emperic abx?
If neuro deficits, age > 65, or papilledema.
Ceftriaxone
230
Characteristics of Idiopathic Intracranial Htn (pseudotumor cerebri)? Dx? When to be nervous?
Young obese women of child bearing age. Worsened HA w/ eye movement or valsalva. Some have papilledema or visual field defects. Dx with normal neuroimaging and opening LP pressure > 200
When visual phenomena occur - then use acetazolamide and furosemide
231
Carotid artery dissection triad?
Unilateral HA, ipsilateral partial Horner syndrome, and contralateral hemispheric findings
232
Trmt of Trigeminal neuralgia?
Carbamazepine
233
Post-herpetic neuralgia trmt?
Gabapentin, phenytoin, or amitriptyline
234
Tension HA trmt?
Acetominophen and NSAIDS. If refractory, Propanolol, Amitriptyline, Desipramine
235
Contraindication to triptans or ergots?
Contraindications
to triptans or ergots include pregnancy, hypertension, coronary artery disease,
or use of either class of agent within the last 24 hours.
236
How do post-concussive HA's present?
Variable in frequency, location, and associated symptoms
237
Major risk pts are at s/p TIA resolution?
Ischemic stroke within 5yrs
238
Trmt of Guillan BArre?
Plasma exchange and IVIG
239
Signs of hypercalcemia?
bony and abdominal pain,
renal stones, and altered mental status (remembered by: “bones, stones, groans,
and psychiatric overtones”).
240
Restriction for fibrinolytics?
BP > 185/110, LP within 7 days, 2 weeks major surg or trauma, active bleeding within 3 weeks OR if pts had symptoms when waking up
241
Lambert eaton associated with what lung ca?
Small cell
242
Findings in vertebrobasilar artery stroke?
3 D's = Dysphagia, Dizziness, and Diplopia - region supplied by PCA (brainstem, cerebellum, and visual cortex)
243
Initial trmt of hypercalcemia?
Aggressive isotonic saline IV hydration
244
How can you tell central cause of CN VII lesions vs. Bell's Palsy?
Central lesion leaves the forehead spared
245
Think of this when people p/w vertigo with arm movement and pain?
Subclavian steal syndrome
246
MCC of impetigo?
Strep Pyogenes or Group A Streptococcus (GAS) and Staph- treat with erythromycin or cephalexin. Topical mupirocen is really effective
247
Triad of intussception? Trmt/test? MC age?
Colicky, vomitting, and red-currant stools - but kids also just become very sleepy in-between bouts of this! Air enema can be diagnostic and therapeutic. Age 3 - 12mo!
248
Presentation of acute chest syndrome?
PNA w/ pulmonary infarct, hypoxia, and pulmonary edema in SSD
249
Differentiate transient tenosynovitis and septic in kid?
Any little movement with septic = tons of pain. Kids get a lot better with rest and NSAIDS in transient or toxic synovitis and can typically move limb a little
250
Kawasaki p/w? Trmt? Complications?
Fever + oral findings (dry lips, strawberry tongue), lymphadenopathy >1.5 cm, diffuse nonvesicular rash, conjunctivitis w/o purulent discharge and swollen hands/feet. IVIG and aspirin. Coronary artery aneurysms
251
What keeps ductus from closing in pt who is 3-7days old and experiencing heart failure/cyanosis?
Prostaglandin
252
Presentation time for pyloric stenosis?
3-6 weeks
253
Baby with dry cough, bilateral eye discharge, maternal infxn ?
Chlamydia - systemic oral erythromycin
254
Knee pain referred to hip in young adolescent overweight male?
Slipped capital femoral epiphysis
255
Organism associated with HSP? Complication? Trmt?
Campylobacter Jejuni - intussusception - steroids and symptomatic trmt
256
Trmt for AOM?
analgesia and observation for 2-3 days - high dose amox if refractory (80-90 mg)
257
MCC of pediatric sepsis?
within 90 days having bacteremia = GBS > E. Coli
258
Pt at risk for epiglottitis?
Unimmunized or recently immigrated - 2/2 HiB.
259
Calculate kid ETT tube:
Cuffed = age/4 + 3
Uncuffed = age/4 + 4
260
What objections should you consider removing from a child's stomach?
Bigger than 2x5cm, sharp objects, or batteries
261
Name MCC:
1) Bronchiolitis
2) Croup
1) RSV
| 2) Parainfluenza virus - racemic epi + steroids
262
Trmt of paraphymosis?
Attempt manual reduction first. Can try dorsal penile block. Dorsal slit or circumcision are last resorts.
263
Malrotation with midgut volvulus imaging? P/W?
Upper GI series - green bilious vomitting, distended or hypertympanic abdomen. Double bubble
264
Volkmann ischemic contracture is a complication of what?
Supracondylar fracture in kids. Type II/III fractures need internal fixation - those that are at risk have difficulty with passive extension of fingers or tenderness of forearm
265
B-hcg levels to visualize fetus via U/S?
>1500 for TV and >6500 TA
266
Molar preg RF's and signs - trmt? and Complication?
P/w extreme N/V, larger uterus than dates, elevated B-hcg, passage of grapes. RF= previous molar, early/late maternal age . D/C and monitor B-hcg levels. Comp = choriocarcinoma
267
Test for endometriosis?
Laparoscopy
268
Progesterone level of what can help tell ectopic
< 5 with positive B-hcg and no IUP seen
269
MCC of miliaria rubra and p/w?
Heat rash, sweat gland blockage with infxn from staph aureus and become vesicular lesions where covered by clothes - extremely itchy - use chlorhexadine.
270
Lab that distinguishes heat stroke from exhaustion?
Hepatic transaminases are in thousands for heat exhaustion but in the ten-thousands for heat stroke
271
With chemical burns containing hydrofluoric acid (rust remover) have pain out of proportion - trmt?
The ions in the chemical bind to cellular ions causing cell death and rapid necrosis - give topic calcium gluconate!
272
Alkali burns form what kind of tissue necrosis?
Liquefactive - need intense irrigation vs. acid causing coagulative necrosis
273
Abx for cat bite?
Augmentin - again pasteurella multocida
274
Parkland formula for fluid admin?
4mL/kg/%TBSA - 1/2 given in first 8 hrs and second half over the next 16 hrs. Silver sulfadiazine dressing, analgesics, and protect against hypothermia
275
Types of burn?
1st degree = red like sun burn
2nd = blistering
3rd = pale, white, charred
4th = through muscle etc limb threatening
276
Burn %'s
Upper body and head surface (a/p) = 4.5 or 9% for entire limb. For lower extremity, each side is 9% or 18 for entire limb. Chest and abdomen = 9% each per side
277
Trmt for acute mountain sickness =?
Descent, O2, acetazolamide
278
For possible bat bite?
Rabies immune globulin and vaccination against rabies
