EM3 M4 Flashcards
hypertensive emergency aka aka
define
9 examples
hypertensive emergency aka malignant hypertension aka hypertensive crisis
defined as hypertension with end-organ damage
eg hypertensive encephalopathy, intracerebral hemorrhage, hypertensive retinopathy, heart failure and pulmonary edema, acute coronary syndrome, acute renal failure, aortic dissection, eclampsia
5 ocular signs of hypertension
5 ocular signs of hypertension
- arterio-venous nicking
- linear or flame-shaped hemorrhages and cotton wool patches (infarction of nerve layer from arteriolar occlusion)
- copper or silver arteriole discoloration from sclerotic changes
- lipid (hard) exudates from htn permeability changes
- optic disc edema from infarction of optic disk is hallmark of malignant hypertension
treat htn in aortic dissection
sublingual nifedipine?
propanolol (bb) and nitroprusside (vasodilator)
with SBP goal 120, or if htn emergency goal 20-25% reduction in 30-60 minutes, or if htn urgency goal reduce over hours to days
NOT sublingual nifedipine – dangerous overshoot BP reduction
selectiveness of labetalol propranolol metoprolol atenolol esmolol
which has elimination half life of minutes
labetolol - nonselective beta also alpha blocking
propanolol - nonselective beta block
metoprolol atenolol esmolol - beta 1 selective
esmolol has elimination half-life of minutes
treat htn from pheochromocytoma with ___ not ___
why
alternatives
treat htn from pheochromocytoma with Alpha blockade NOT beta blockade… contraindicated till after alpha blockade to avoid paradoxical increase in blood pressure due to antagonism of skeletal muscle vasodilation
nitroprusside CCBs ACEIs alternatives to alpha blockade
what is the goal for malignant htn after reducing SBP 25-30% in the first hour
SBP reduction 25-30% in first 30-60min
then 160/100 in 2-6 hours of treatment
preferred initial agent for treating hypertensive emergency
esmolol IV
100-500 mic/kg load
TF
shingles can present after mechanical trauma
treat in ED
T
shingles can present after mechanical trauma
discharge home with analgesics and acyclovir
etiology of stasis dermatitis
impaired oxygen delivery to skin and subcutaneous tissue… gradual and chronic
Smallpox incubation period __ weeks.
__ day prodromal phase characterized by ____.
temperature subsides over __ days.
____ precedes skin rash by a day.
Skin rash begins as ____ which become ____ then ____ then ____ then ____ over the course of ____.
lesions occur first ____ then spread to ____.
Distribution is ___ and lesions are all at ____ stage of development.
Death from smallpox is from ____
Smallpox incubation period 1.5-2 weeks.
2-3 day prodromal phase characterized by fever headache backache.
temperature subsides over 2-3 days.
Enanthem over tongue mouth and oropharynx precedes skin rash by a day.
Skin rash begins as small reddish Macule which become Papules then Vesicles then Pustules then Umbilication and Crusting over the course of ~2 weeks.
lesions occur first on Face and Extremities then spread to Cover the Body.
Distribution is Peripheral and Centrifugal and lesions are all at The Same stage of development.
Death from smallpox is from Toxemia from immune complex deposition and HypOtension.
Diagnosis:
incubation period 1.5-2 weeks.
2-3 day prodromal phase characterized by fever headache backache.
temperature subsides over 2-3 days.
Enanthem over tongue mouth and oropharynx precedes skin rash by a day.
Skin rash begins as small reddish Macule which become Papules then Vesicles then Pustules then Umbilication and Crusting over the course of ~2 weeks.
lesions occur first on Face and Extremities then spread to Cover the Body.
Distribution is Peripheral and Centrifugal and lesions are all at The Same stage of development.
Death is from Toxemia from immune complex deposition and HypOtension.
Smallpox
incubation period 1.5-2 weeks.
2-3 day prodromal phase characterized by fever headache backache.
temperature subsides over 2-3 days.
Enanthem over tongue mouth and oropharynx precedes skin rash by a day.
Skin rash begins as small reddish Macule which become Papules then Vesicles then Pustules then Umbilication and Crusting over the course of ~2 weeks.
lesions occur first on Face and Extremities then spread to Cover the Body.
Distribution is Peripheral and Centrifugal and lesions are all at The Same stage of development.
Death from smallpox is from Toxemia from immune complex deposition and HypOtension.
Erythema Multiforme exists on a spectrum with ___ and ___ and causes include…. such as…
Erythema Multiform/Stevens-Johnson/Toxic Epidermal Necrolysis exist on a spectrum
causes include drugs (sulfa antibiotics, penicillins, barbiturates), viral or mycoplasma infections, recent immunization
treat cellulitis vs recurrent cellulitis in diabetic
cellulitis - cover GPCs staph and strep… penicillinase-resistant penicillins (dicloxacillin nafcillin oxacillin)… or 1st generation cephalosporins (cephalexin cefazolin)
recurrent cellulitis in diabetic- cover GPCs and GNRs… broader spectrum… Unsayn (Ampicillin-Sulbactam)
when (ages) is seborrheic dermatitis common vs uncommon
treat seborrheic dermititis
topical steroids?
common in infants and elderly
uncommon between infancy and puberty
treat with anti-dandruff shampoo
NOT steroids
what rash is associated with an anterior and posterior thorax Christmas-tree pattern distribution
pityriasis rosacea
is associated with an anterior and posterior thorax Christmas-tree pattern rash distribution
what color under Woods Lamp UV light? erythrasma tinea versicolor pseudomonas porphyria cutanea
what color under Woods Lamp UV light? erythrasma - red/pink tinea versicolor - green/yellow pseudomonas - yellow/green porphyria cutanea - urine orange/yellow
to achieve large differences in potency of topical steroid, is it more effective to switch agents or vary the dose of the same agent?
it is more effective to switch agents to achieve large differences in potency of topical steroid… changing dose does not affect potency much
how is potency of topical steroid measured
potency of topical steroid is measured by the ability to induce vasoconstriction
why are interrupted application schedules of topical steroid use preferred
because tachyphylaxis (vasoconstriction in response to corticosteroid use decreases over time), so on 2 weeks off 1 week preferred
____ steroids are to be avoided in pregnant women
Fluorinated steroids are to be avoided in pregnant women
is topical Hydrocortisone preferred for thick or thin skin?
topical Hydrocortisone preferred for Thin skin… relatively low potency steroid
Treat diffuse pruritus of most of the body
First gen second gen antihistamine?
Topical PO IV?
Anything else?
First gen ok second gen antihistamine lower dose frequency requirement and less sedation but more costly
PO ok can also do IV if necessary, not topical becuase can overdose when spreading over large area hard to estimate total dosing
Baths and soaks too
____ are white in color, greasy in texture and can be applied to any body surface area. These characteristics make them the most versatile vehicle. ____ are for acute use only; chronic use leads to drying of the skin. ____ are composed of greases such as petroleum jelly with little water added. ____ can help lubricate skin lesions that are particularly dry. ____ are greaseless mixtures of propylene glycol with water and may or may not contain alcohol. ____ are drying and are best for exudative lesions such as poison ivy but will cause discomfort in denuded areas. ____ are used for dry scaly conditions.
Creams are white in color, greasy in texture and can be applied to any body surface area. These characteristics make them the most versatile vehicle. Creams are for acute use only; chronic use leads to drying of the skin. Ointments are composed of greases such as petroleum jelly with little water added. Ointments can help lubricate skin lesions that are particularly dry. Gels are greaseless mixtures of propylene glycol with water and may or may not contain alcohol. Alcohol-containing gels are drying and are best for exudative lesions such as poison ivy but will cause discomfort in denuded areas. Alcohol-free gels are used for dry scaly conditions.
Tzanck preparation can identify the ____ but cannot distinguish among them
Tzanck preparation can identify the herpes viruses but cannot distinguish among them
What is the mortality rate of eczema herpeticum
What is the presentation and diagnosis of eczema herpeticum
10% mortality with eczema herpeticum (eczema with positive tzank smear for a herpes virus HSV OR VZV)… constitutional symptoms, adenopathy in addition to rash… — so consult dermatology immediately
Rocky mountain spotted fever
Prodrome of ___ ___ ___
Symtpoms of ___ ___ ___ and rash that is ____ begins ____ and spreads to ____ within __ to __ hours
Caused by ____
95% of patients develop symptoms between ___ and ___ dates
A skin biopsy shows ____
Rocky mountain spotted fever
Prodrome of fever chills anorexia
Symtpoms of headache photophobia myalgias and rash that is non-blanching papular, begins wrists forearms ankles and spreads centripitally up legs and arms to trunk neck face within 6 to 18 hours
Caused by Rickettsia Rickettsi
95% of patients develop symptoms between April 1st and September 30th dates
A skin biopsy shows necrotizing vasculitis
Scabies
Treatment is ____. Often this condition occurs in young adults by ____ or in the elderly ____ population. The organism involved does not penetrate the ____ for it relies on ____ for survival. ____ therapy may be needed if ____ develops, suggested by ____. The parasite is a ____ known as ____.
Scabies
Treatment is permethrin 5% cream applied to skin for 8-12 hours. Often this condition occurs in young adults by sexual contact or in the elderly hospitalized population. The organism involved does not penetrate the dermis for it relies on oxygen for survival. Antibiotic therapy may be needed if bacterial superinfection develops, suggested by surrounding erythema. The parasite is a mite known as Sarcopetes scabii.
Poison ivy/oak is classified as a ____. Although the rash can be expected to resolve on its own (i.e. without medical intervention) in ___ weeks, relief can be facilitated with ____ therapy and/or ____ treatment. The bullae can be drained for ____ purposes, but the tops should not be removed to avoid risk for ____. This condition is due to exposure to ____, which may remain on ____ until it is ____. The allergen ____ present in the bullae of vesicles and so, after the initial washing of the involved site, contact with the rash ____ cause it to spread.
Poison ivy/oak is classified as a allergic contact dermatitis, a type-IV hypersensitivity reaction. Although the rash can be expected to resolve on its own (i.e. without medical intervention) in 1-2 weeks, relief can be facilitated with antihistamine therapy and/or oral steroid treatment. The bullae can be drained for cosmetic purposes, but the tops should not be removed to avoid risk for bacterial superinfection. This condition is due to exposure to allergenic plant oleresins, which may remain on the clothing that the patient was wearing at the time of contact until it is washed. The allergen is not present in the bullae of vesicles and so, after the initial washing of the involved site, contact with the rash does not cause it to spread.
____ can cause periodic muscle paralysis and areflexia. ____ can cause tetany and weakness. Low ____ levels can contribute to myocardial dysfunction, CNS symptoms, muscle weakness and bleeding disorders. ____ can cause a clouded sensorium and other neurological deficiencies. Chronic ____ deficiency leads to dermatologic consequences,
including patches and plaques of dry, scaly, sharply marginated and brightly red eczematous dermatitis evolving into vesiculobullous, pustular, erosive, and crusted lesions that initially involve the ____ and ____ areas. Progression can involve the scalp, hands, feet, trunk and flexural regions. There may be diffuse alopecia and graying of remaining hair. Nail manifestations may include ____ or ____. A ____ tongue is common, and the oropharynx may reveal ____. Patients with ____ deficiency tend to be photophobic, irritable, and depressed. Treatment of deficiency consists of ____ for ___ weeks.
Hypokalemia can cause periodic muscle paralysis and areflexia. Hypocalcemia can cause tetany and weakness. Low phosphorus levels can contribute to myocardial dysfunction, CNS symptoms, muscle weakness and bleeding disorders. Hypomagnesemia can cause a clouded sensorium and other neurological deficiencies. Chronic zinc deficiency leads to the dermatologic consequences including patches and plaques of dry, scaly, sharply marginated and brightly red eczematous dermatitis evolving into vesiculobullous, pustular, erosive, and crusted lesions that initially involve the perioral and anogenital areas. Progression can involve the scalp, hands, feet, trunk and flexural regions. There may be diffuse alopecia and graying of remaining hair. Nail manifestations may include loss of nails or paronychia. A red, glossy tongue is common, and the oropharynx may reveal aphthous-like ulcers. Patients with zinc deficiency tend to be photophobic, irritable, and depressed. Treatment of zinc deficiency consists of dietary or intravenous zinc salt supplementation for 2-3 weeks.
Name 4 skin conditions that cvan be associated with malignancy
Erythema nodosun
Acanthosis nogracans
Dermatomyositis
Pruritis
Dermatological anthrax may occur wherever ____. Antibiotics ____ affect the course of local disease. Characteristic lesion is a ____ preceded by a ____ 1 week prior. The organism most likely to cause dermatological anthrax is ____. Mortality rates are ____ than for pulmonary anthrax. Diagnosis of cutaneous anthrax is usually made ____ often after determining ____ while taking the history. In the future, ____ may become widely available and useful to make definitive diagnoses. Treatment for cutaneous anthrax is aimed at preventing the ____ which is complicated by a significantly higher mortality.
Dermatological anthrax may occur wherever slores contact skin. Antibiotics do not affect the course of local disease. Characteristic lesion is a black eschar preceded by a vesiculopapular lesion 1 week prior. The organism most likely to cause dermatological anthrax is bacillus anthrasis. Mortality rates are over 20-30% lower than for pulmonary anthrax. Diagnosis of cutaneous anthrax is usually made on a clinical basis, often after determining patient exposure while taking the history. In the future, PCR methods may become widely available and useful to make definitive diagnoses. Treatment for cutaneous anthrax is aimed at preventing the dissemination of a disease which is complicated by a significantly higher mortality.
Regarding urticaria
Association with malignancy ____ strong enough to investigate for possible cancer when urticaria of unknown origin exists. ____ are the most common offenders. Nonimmunological urticaria may be caused by ____. Drug-induced urticaria may be ____ or ____. Precipitants of urticaria include…… Drug-induced urticaria ____ represent anaphylaxis or indicate its impending development so ____ are usually not indicated. Treatment may only include stopping ____ and administering ____. Although ____ and ____ are the most common precipitants, drug-induced urticaria has been demonstrated after use of ____.
Regarding urticaria
Association with malignancy is not strong enough to investigate for possible cancer when urticaria of unknown origin exists. Panicillins and Opiates are the most common offenders. Nonimmunological urticaria may be caused by degranulation of mast cells. Drug-induced urticaria may be immunologic or nonimmunilogic. Precipitants of urticaria include food allergies, cold induced, malignancy, SLE, familial, exercise, excessive heat, etc. Drug-induced urticaria does not represent anaphylaxis or indicate its impending development so steroids are usually not indicated. Treatment may only include stopping the offending agent and administering antihistamines or other antipruritics as needed. Although penicillins and opiates are the most common precipitants, drug-induced urticaria has been demonstrated after use of an enormous number of medications.
Describe the rash lf meningococcemia
palpable petechiae with pale gray centers, usually on the wrists, ankles, flanks, and axilla
ITP (immune thrombocytopenic purpura)
____ tranfusion can induce ____ and worsen the patient’s condition by increasing ____. ____ is the most feared complication of ITP. ____/mm3 is a commonly cited platelet threshold for ____). The __ is expected to be normal, and intra-articular bleeding ____ a major feature of ITP. ____ are usually indicated for adults
ITP (immune thrombocytopenic purpura)
Platelet transfusions can induce inflammatory (autoantibody) response and worsen the patient’s condition by increasing platelet destruction. Intracranial hemorrhage is the most feared complication of ITP, (20,000/mm3 is a commonly cited threshold for spontaneous intracranial bleeding). The PT is expected to be normal, and intra-articular bleeding is not a major feature of ITP. Steroids are usually indicated for adults
