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CSI 2 > emergency medicine > Flashcards

emergency medicine Flashcards

1
Q

what are the 2 parts that make up an altered mental state?

A

level of consciousness (attentiveness)

cognition (mental processes or thoughts)

disorders may be of 1 or both

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2
Q

what is a symptom sieve?

A

broad categories of pathological processes that cause a symptom or disease

e.g. trauma, autoimmune

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3
Q

what is the symptom sieve for patients with altered mental state?

A

Psychiatric

Endocrine/Metabolic

Toxins

Primary Neurological

Infection

Gastro-intestinal

Cardiorespiratory

(PET PIG C)

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4
Q

what is the assessment of Bill’s airway (A)?

A

intermittent verbalisation

no foreign objects in mouth or excessive secretions

no snoring, no stridor

no mouth or tongue swelling

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5
Q

what is the assessment of Bill’s breathing (B)?

A

respiratory rate - 14 breaths/minute

oxygen saturation - initially 90%, 94% after 2l oxygen

no evidence of respiratory distress

mild wheeze

smoker

(abdominal distention could affect respiration, affect diaphragm)

(check compromised/scalene muscles - also assist in breathing, and affect respiration if damaged)

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6
Q

what is the assessment of Bill’s circulation (C)?

A

BP 89/64 mm Hg

heart rate - 110 bpm, regular (high)

heart sounds - normal

12 lead ECG - sinus tachycardia, no ischaemic changes

peripheral capillary refill brisk bilaterally (under 2 secs - liver failure?)

warm peripheries, looks flushed

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7
Q

which of Bill’s circulation stats is the most worrying?

A

low blood pressure (89/64 mmHg)

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8
Q

what are the 4 types of shock?

A

cardiogenic

hypovolemic

obstructive

distributive

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9
Q

what are the 3 types of distributive shock?

A

septic

anaphylactic

neurogenic

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10
Q

what is hypovolemic shock?

A

result of loss of high volume of fluid

heart cannot pump enough blood, can lead to organ failure

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11
Q

what is cardiogenic shock?

A

heart suddenly can’t pump enough blood to meet your body’s needs

often caused by a severe heart attack

peripheries are cold, pulmonary oedema

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12
Q

what is obstructive shock?

A

physical obstruction of vessels

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13
Q

what is distributive shock?

A

due to excessive vasodilation

abnormal distribution of blood flow in the smallest blood vessels results in inadequate supply of blood to the body’s tissues and organs

total peripheral resistance drops and so blood pressure drops

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14
Q

what is the assessment of Bill’s disability (D)?

A

blood glucose - 5.7

temperature - 38.2 degrees

confused (ACVPU - alert, confusion, voice, pain, unresponsive)
GCS E3 V4 M5
(eyes, verbal, motor on scale of 1 to 5, 1 being the lowest)

4 limbs moving normally

PEARL (pupils equal and reactive to light) - 3mm

probably intoxicated

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15
Q

what is the assessment of Bill’s exposure (E)?

A

no rashes

no sites of injection/track marks

no evidence of trauma to limbs or head

no evidence of external bleeding

abdominal examination - abdomen distended, tender in left iliac fossa

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16
Q

how is SIRS diagnosed?

A

2 or more of:

  • temperature lower than 36 degrees or higher than 38 degrees
  • heart rate over 90bpm
  • respiratory rate over 20
  • WBC over 12 x 10⁹/L or under 4 x 10⁹L
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17
Q

how is sepsis diagnosed? what tests must be done to check?

A

meets SIRS criteria with evidence of infection

take blood cultures

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18
Q

how is severe sepsis diagnosed? what tests must be done to check?

A

sepsis with evidence of organ dysfunction, hypotension or hypoperfusion

lactate and urine output

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19
Q

how is severe sepsis diagnosed?

A

severe sepsis with hypotension despite adequate fluid resuscitation

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20
Q

what are the 6 steps to treat suspected sepsis?

A

give oxygen (keep sats above 94%)

take blood cultures

give IV antibiotics

give fluid challenge (give fluid and check effect on blood pressure)

measure lactate (kidneys - check perfusion)

measure urine output

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21
Q

what are the 2 different impressions given of Bill?

A

sepsis

altered mental state due to (sepsis), alcohol, delirium, drugs and intercranial pathology

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22
Q

what tests have to be done after the initial impressions of Bill?

A

sepsis management

investigate source of sepsis

CT scan to rule out intracranial pathology

toxicology screen (rule out alcohol etc.)

blood culture

biochemistry: CRP, creatinine, urea, Na, K, ALT, ALP, GGT, bilirubin, amylase, lactate
haematology: Hb, WCC, Neut, PLT

23
Q

which biochemistry results support a diagnosis of sepsis?

A

high CRP - marker of inflammation, link to infection

high creatinine, urea - indicative of kidney and renal problems, maybe hypoperfusion

high WBC, Neut - inflammation

high lactate - marker for sepsis

(high GGT and ethanol probably due to alcohol, nothing to do with sepsis)

(all negative on toxicology, so not drug effect)

24
Q

what are the steps to take after the toxicology screen?

A

analgesia for pain in abdomen

CT abdomen and pelvis

continue IV fluids, antibiotics

25
Q

what does a NEWS score of 3 indicate?

A

no need for escalation

26
Q

what are the 3 most likely causes of Bill’s confusion from the symptom sieve?

A

infection

gastro-intestinal

toxins

27
Q

since the pain is localised in the left iliac fossa, what organ (s) may be causing Bill’s pain?

A

sigmoid and descending colon

could also be kidney or bladder

(if female could also be uterus, womb, ovaries - do a pregnancy test)

28
Q

what condition is Bill likely to have?

A

probably not appendicitis due to age, appendix is generally in right fossa

acute kidney injury - would have showed in other tests

colorectal adenocarcinoma - can be seen on CT

sigmoid diverticulitis most likely (multiple diverticulae are seen, sigmoid colon displays wall thickening - peri colic fat stranding is also sign of diverticulitis)

29
Q

what is a diverticulum?

A

small, bulging pouch that can form in the lining of digestive system, more common with increasing age

use ultrasound to detect

30
Q

what is the difference between diverticulitis and diverticulosis?

A

diverticulitis: outpouching with infection/inflammation

faeces gets trapped and stagnates in a diverticulum, causes overgrowth of gut bacteria

diverticulosis: outpouching without inflammation

31
Q

what does diverticular disease cause?

A

diverticula cause intermittent abdominal (usually left) cramp-like pain, bloating (without swelling (inflammation) or infection)

get ease from pain and bloating by passing stools

some may develop diarrhoea or constipation, and some people pass mucus with their stools - unclear how diverticula causes this

(symptoms can be similar to IBS - however, IBS usually affects younger adults)

diagnosis: confirm presence of diverticula, rule out other causes of symptoms.

symptoms of diverticular disease, especially if they start in an older person, can also be similar to those of early bowel cancer so tell a doctor if you develop these symptoms, as some tests may need to be arranged (e.g. colonoscopy)

diverticula may occasionally bleed abruptly and painlessly due to a burst blood vessel that sometimes occurs in the wall of a diverticulum- go see a doctor (in case of bowel cancer etc.)

32
Q

what is in the right upper quadrant of the abdominopelvic region?

A

right liver

gallbladder

right kidney

small part of stomach

duodenum

head or pancreas

portions of ascending and transverse colon

parts of small intestine

33
Q

what is pain in the right upper quadrant associated with?

A

infection/inflammation in gallbladder and liver

peptic ulcers

34
Q

what is in the left upper quadrant of the abdominopelvic region?

A

left portion of the liver

part of the stomach

pancreas

left kidney

spleen

portions of the transverse and descending colon

parts of the small intestine

35
Q

what is pain in the left upper quadrant associated with?

A

malrotation of the intestine and colon

36
Q

what is in the right lower quadrant of the abdominopelvic region?

A

cecum

appendix

part of the small intestines

right half of the female reproductive system

right ureter

37
Q

what is pain in the right lower quadrant associated with?

A

appendicitis

38
Q

what is in the left lower quadrant of the abdominopelvic region?

A

majority of the small intestine

some of the large intestine

left half of the female reproductive system

left ureter

39
Q

what is pain in the left lower quadrant associated with?

A

colitis (inflammation of the large intestine)

pelvic inflammatory disease

ovarian cysts

40
Q

what does the right hypochondriac region contain?

A

right portion of the liver

gallbladder

right kidney

parts of the small intestine

41
Q

what does the left hypochondriac region contain?

A

part of the spleen

left kidney

part of the stomach

pancreas

parts of the colon

42
Q

what does the epigastric region contain?

A

majority of the stomach

part of the liver

part of the pancreas

part of the duodenum

part of the spleen

adrenal glands

43
Q

what does the right lumbar region contain?

A

gallbladder

left kidney

part of the liver

ascending colon

44
Q

what does the left lumbar region contain?

A

descending colon

left kidney

part of the spleen

45
Q

what does the umbilical region contain?

A

umbilicus (navel)

many parts of the small intestine

part of the duodenum, the jejunum, and illeum

transverse colon

bottom portions of both the left and right kidney

46
Q

what does the right iliac/inguinal region contain?

A

appendix

cecum

right iliac fossa

47
Q

what does pain in the right iliac region indicate?

A

appendicitis

48
Q

what does the left iliac/inguinal region contain?

A

descending colon

sigmoid colon

left iliac fossa

49
Q

what does the hypogastric region contain?

A

bladder

part of the sigmoid colon

anus

most of reproductive system (uterus and ovaries in females, prostate in males)

50
Q

why do diverticula develop?

A

lack of fibre

gut moves stools along by muscular wall movements

stools tend to be drier, smaller, and more difficult to move along if you don’t eat much fibre - muscles have to work harder if there is too little fibre in your gut

high pressure may develop in parts of your gut when it squeezes hard stools

increased pressure may push the inner lining of a small area of your gut through the muscle wall to form a small diverticulum

51
Q

what are the symptoms of diverticulitis?

A

constant pain in the abdomen (commonly in the lower left side of the abdomen, but can occur in any part of the abdomen - in people of Asian origin, it sometimes occurs on the right side)

high temperature (fever)

constipation or diarrhoea

some blood mixed with your stools

nausea or vomiting

52
Q

what are some complications caused by diverticulitis?

A

obstruction of the colon

abscess may form in the abdomen

channel (fistula) that may form to other organs such as the bladder

perforation in the wall of the bowel that can lead to infection inside the abdomen (peritonitis)

53
Q

how is diverticulosis treated?

A

high fibre diet (about 18g per day)

with high fibre, lots of fluid (at least 2l per day)

paracetamol to ease pain (NSAIDs and opioids should be avoided as they can cause perforation)

antispasmodics such as mebeverine if you have persistent abdominal spasms

54
Q

how is diverticulitis treated?

A

if generally unwell: antibiotics, high fibre diet, maybe strong painkillers

if symptoms are severe/prolonged: hospitalised - IV drip, antibiotics

if any complications, surgery is needed (e.g. to drain abscess, remove infected colon)

CSI 2 (6 decks)

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