Emergency Medicine EOR Flashcards
Shoulder impingement syndrome is caused by compression of the tendon of what muscle?
Supraspinatus
What physical exam special test finding is most consistent with shoulder impingement syndrome?
A positive hawkins-kennedy test
How is the Hawkins-Kennedy test preformed?
What is a positive test?
- Stabilize shoulder
- Flex elbow 90 degrees
- Internally rotate shoulder
Positive test = pain with internal rotation
What is the most common risk factor for shoulder impingement syndrome?
Repetitive overhead activity
Treatment for shoulder impingement syndrome?
Rest, ice, NSAIDs, physical therapy
A positive O’Brien test indicates an injury where?
Superior labrum anterior and posterior tear
What indicates a positive O’Brien test?
While shoulder is flexed to 90 degrees, pain with downward pressure while internally rotated, and relief of pain with downward pressure while externally rotated.
A Speed test is used to evaluate for what injury?
Bicipital tendinitis
What is a Homans test used to evaluate?
For DVT
Which rotator cuff muscle is most commonly injured, inflamed, or torn?
The supraspinatus muscle.
What is the classic triad of symptoms for bacterial meningitis?
Fever, confusion, neck stiffness.
What are the most common causative agents of bacterial meningitis in adults?
Strep pneumo and Neisseria meningitidis
What are the typical CSF analysis results in bacterial meningitis?
Cloudy/purulent fluid CSF glucose <40% of serum glucose WBC count >1000, predominantly polymorphonucleocytes (PMNs) Elevated opening pressure Increased protein level
What is a normal opening pressure for a lumbar puncture?
6-20
How would you expect CSF analysis results to differ in mycobacterium tuberculosis meningitis or fungal meningitis when compared to strep pneumo meningitis?
TB meningitis and fungal meningitis should have similar results, but cell count is typically lower, between 10-1000 cells/microL, with a predominance of lymphocytes rather than PMNs
What CSF analysis results would you expect in viral meningitis?
Clear fluid appearance
Normal-slightly elevated opening pressure
WBC count 25-2000 with lymphocyte predominance
Elevated protein
CSF glucose >60% serum glucose
Why is dexamethasone administered with antibiotics for suspected meningitis?
Decrease in mortality and long-term morbidity (e.g. hearing loss).
What two physical exam findings would you expect to be positive in a patient with meningitis?
Brudzinski's sign (neck) Kernig sign (Knee)
What causative agent of meningitis should you have concern for in HIV patients?
Cryptococcus
What is the empiric treatment for bacterial meningitis in a 18-50 year old patient?
Ceftriaxone + vancomycin
What is the empiric treatment for bacterial meningitis in a >50 year old patient?
Ceftriaxone + vancomycin + ampicillin (to cover Listeria)
Which are painful, internal or external hemorrhoids?
External (below dentate line)
What patients with thrombosed external hemorrhoids are good candidates for hemorrhoid excision?
Patient with acute (less than 48 hours) sever symptoms in otherwise healthy patients?
What patients should not have thrombosed hemorrhoids excised in the ED?
Immunocompromised patients, pregnant patients, patients with coagulopathies, and patients with symptoms >48 hours.
What type of excision should be made to remove a thrombosed hemorrhoid?
Elliptical incision
If a patient is not a good candidate for excision of a thrombosed hemorrhoid, what is the recommended treatment?
Stool softeners, sitz baths, PCP follow up.
How is rectal bleeding associated with hemorrhoids typically described?
Limited, at the end of defecation, either dripping into the bowl or on tissue paper.
What is the most consistent finding in patients with cauda equina syndrome?
Urinary retention
What imaging should you order emergently for patients you suspect cauda equina syndrome?
MRI
What is the treatment for cauda equina syndrome?
emergency surgery
What is the treatment for cauda equina syndrome secondary to a malignancy?
Emergent radiation therapy.
What is the reversal agent for warfarin?
Vitamin K
What is the INR goal for DVT prevention?
2-3
For a patient with an INR of 12, with no bleeding, what is the treatment?
Oral vitamin K, hold next warfarin dose, repeat labs in 24-48 hours.
What is the treatment for a patient with an INR of 8, with no bleeding?
Hold warfarin, no vitamin K necessary.
What is the pharmacologic treatment for a patient on warfarin with any INR, who has serious bleeding?
Four-factor prothrombin complex concentrate (4-factor PCC)
IV vitamin K
Hold warfarin
What blood product may be used to reverse warfarin?
Fresh frozen plasma.
A patient suspected of acute coronary syndrome has an elevated troponin without ST segment changes or T wave abnormalities. They have been given nitroglycerin, aspirin, an IV, and are being prepared for PCI. What other medication do they still need?
Ticagrelor (which is a P2Y12 adenosine diphosphate platelet receptor antagonist (P2Y12 antagonist))
Why is ticagrelor preferred over other P2Y12 anatagnoists such as clopidogrel or prasugrel in patients with ACS?
Studies have shown that it provides faster, greater, and more consistent ADP receptor inhibition
What is the dose of Ticagrelor that should be given for ACS?
180mg by mouth
What type of medication is tenecteplase?
A tissue plasminogen activator variant
When should Tenecteplase be given for ACS?
If PCI is thought to be longer than 120 minutes from first medical contact.
What are two modalities to evaluate for low-probability (patients with normal cardiac serum biomarkers and no acute ischemic ECG changes) ACS?
CT coronary angiography and nuclear medicine testing
What antiplatelet agent should be given to patients with ACS who have a true aspirin allergy?
Clopidogrel.
What is the pathophysiological of the disease process causing PSGN?
Immune complex deposition
How long after a strep infection does PSGN usually present?
2 weeks
What are the classic symptoms of PSGN?
HTN, edema, tea-colored urine or foamy urine
Urinalysis often shows what in PSGN?
Red blood cell casts and proteinuria
Do antibiotics help lower the incidence of poststreptococcal glomerulonephritis?
No.
What is the treatment for PSGN?
Supportive measures including salt and water restriction, furosemide if edema and HTN are present
What are the two most common risk factors for small bowel obstructions?
Adhesions from previous surgery
Cancer
What is the preferred imaging modality to diagnose a SBO?
CT
What is the most common cause of large bowel obstruction?
Neoplasm.
What is common to see on abd x-ray in a SBO?
Dilated bowel, air fluid levels, stack of coins or string of pearls sign.
Treatment for SBO?
NGT, surgery
What is the cause of a bowing fracture?
What is the treatment?
Cause: Longitudinal compression
Tx: Ortho consult
What is the cause of a greenstick fracture?
What is the treatment?
Cause: Axial compression with twisting
Tx: Casting and reduction
What is the cause of a Torus (Buckle) fracture?
What is the treatment?
Cause: axial compression
Tx: casting
What are two treatment options for acute uncomplicated cystitis?
TMP-SMX or nitrofurantoin x 3-5 days
What are the treatment options and duration for acute uncomplicated cystitis with comorbid conditions?
TMP-SMX or nitrofurantoin or a fluoroquinolone x 7 days
What is the treatment for acute cysitis in men?
TMP-SMX or nitrofurantoin x 7 days or a fluoroquinolone x 5 days
Why is asymptomatic bacteriuria treated in pregnant women?
It has been linked to increased risk of low birth weight infants as well as pyelonephritis in mothers.
What is the outpatient treatment for acute uncomplicated pyelonephritis?
Fluoroquinolone (I dont really know if someone does LMK)
The diagnosis of DKA can be made with the presence of what three findings?
Hyperglycemia, ketosis, and acidemia.
What are the three aims of treatment for DKA?
Insulin therapy, fluid resuscitation, and electrolyte replacement.
What electrolyte abnormality is typically found in DKA?
Hyperkalemia
Why should you give potassium to patients being treated for DKA?
Potassium levels decrease significantly as acidemia is corrected
What is the term for deep and labored breathing seen in patients with diabetic ketoacidosis?
Kussmaul respirations.
What are the 5 I’s that can cause DKA?
Infection, Ischemia (cardiac, mesenteric), Infarction, Insulin deficit (poor control), Intoxication.
What are the symptoms of DKA?
Abd pain, vomiting, fatigue.
What is temporal arteritis associated with?
polymyalgia rheumatica
What are the symptoms of polymyalgia rheumatica?
Anorexia, headache, jaw claudication, and fever.
What is the gold standard for dx of temporal arteritis?
Temporal artery biopsy
What is the treatment for temporal arteritis?
Corticosteroid treatment
What is another large-vessel vasculitis aside from giant cell (or temporal) arteritis?
Takayasu arteritis.
What lab finding is common in temporal arteritis?
Elevated ESR
What are the 6 different types of abortion?
Threatened, inevitable, incomplete, compete, missed, and septic.
The cervical os is open during what types of spontaneous abortion?
Inevitable, incomplete, and septic.
What is the most common pathogen responsible for septic abortion?
Staph aureus
What is the treatment for septic abortion?
evacuation of uterine contents as well as antibiotics (ampicillin-sulbactam or clindamycin + gentamicin)
Carpospasm while checking blood pressure is known as what sign?
Trousseau sign
What does Trousseau sign indicate?
Hypocalcemia
What sign other than Trousseau sign indicates hypocalcemia?
Chvostek sign
Describe a positive Chvostek sign.
Contraction of the ipsilateral facial muscles elicited by tapping the facial nerve just anterior to the ear.
What electrolyte abnormality can cause hemodynamic instability during massive transfusion protocol?
Hypocalcemia. Calcium levels can drop precipitously during transfusion secondary to the citrate present in packed red blood cells.
What ECG findings are associated with pericarditis?
Diffuse ST elevation with reciprocal ST depression in leads aVR and V1.
Describe the pain associated with pericarditis.
Sharp, pleuritic chest pain that is relieved by sitting up and leaning forward.
What is the treatment for pericarditis?
NSAIDs, cholchicine, and steroids for refractory cases.
What viruses commonly cause pericarditis?
Coxsackie viruses A and B, echovirus, adenovirus, HIV, Epstein-Barr virus, influenza, and hepatitis B.
What is the initial monotherapy for a low back strain?
NSAIDs or acetaminophen
What is the second line combination therapy for low back strains?
NSAIDs and muscle relaxants.
How does the back pain of a herniated disc present?
Electrical pain that radiates down the back of the leg.
What is the most common type of mesenteric ischemia?
Arterial embolism
What is the gold standard imaging for diagnosis of mesenteric ichemia?
Mesenteric CT angiography
How long after the onset of bowel ischemia does complete transmural necrosis complete?
Six hours.
What physical exam findings would give you concern for mesenteric ischemia?
Pain out of proportion to exam
What history findings with abdominal pain point towards mesenteric ischemia?
History of dysrhythmias, recent MI, CAD, valvular heart disease, prior thromboembolic events, hypercoagulable states, heart failure.
What lab finding is common in mesenteric ischemia?
Lactic acidosis
What is the difference between relative and absolute polycythemia?
Relative polycythemia is due to a decrease in plasma volume, commonly caused by dehydration or excessive diuresis.
Absolute polycythemia is an increase in RBC mass.
What is the difference between primary and secondary absolute polycythemia?
Primary is due to mutation in erythroid cell lines or EPO receptors.
Secondary is due to increased levels of circulating EPO.
How is polycythemia vera classified?
Polycythemia vera is an absolute primary polycythemia.
What gene mutation is associated with polycythemia vera?
JAK2 gene mutation
What are the classic symptoms of polycythemia vera?
Pruritis, particularly when exposed to hot water, and early satiety.
What is the name of the most life threatening complication of polycythemia vera?
Hyperviscosity syndrome
What is the triad of symptoms associated with hyperviscosity syndrome?
Vision changes, bleeding, and focal neurologic deficits.
Name some physical exam findings consistent with polycythemia vera.
Splenomegaly, plethoric facies, flushed skin, nail clubbing, and distal cyanosis.
What is the treatment for polycythemia vera?
low-dose aspirin and therapeutic phlebotomy.
Other treatments include ruxolitinib (a JAK1 and JAK2 inhibitor.)
What is the treatment for hyperviscosity syndrome?
IV fluid hydration and hematology consult.
What is the term for pruritis following a warm bath of shower?
Aquagenic pruritis
What is a leukemoid reaction?
Significant leukocytosis (50,000/μL) in the absence of hematologic malignancy.
How can you differentiate an ischemic priapism from a nonischemic priapism?
A nonischemic priapism is painless, and the glans is hard.
An ischemic priapism is painful, and the glans is soft. The blood gas has a pH <7.25, pCO2>60 and pO2<40.
What is the treatment for an ischemic priapism?
Corporal aspiration with intracavernosal phenylephrine
What is the initial treatment of ischemic priapism in patients with sickle cell disease?
Initial treatment is the same with aspiration and intracavernosal phenylephrine.
What type of leukemia are the following cells found in:
Auer rods
Smudge cells
Philidelphia chromosome
Auer rods = AML (ask me later, in an auer)
Smudge cells = CLL (the sound it would make if you rolled the car window down with your face pressed against it, and it would leave a smudge)
Philidelphia chromosome = CML (Check My Location)
What is a risk factor for development of CML?
Exposure to ionizing radiation.
Is a spontaneous pneumothorax more common in males or females?
Males:Females = 3:1
What sign seen on supine chest XR is indicative of pneumothorax?
Deep sulcus sign (profound lateral costophrenic angle)
Where should a tube thoracostomy be inserted?
Fourth or fifth intercostal space, above the rib, midaxillary line (usually coincides with nipple line).
What physical exam findings may be present in a spontaneous pneumothorax?
Decreased breath sounds, decreased fremitus, and hyperresonance to percussion
What antibiotic is first line treatment for mastitis?
Dicloxacillin
What is the treatment for a breast abscess?
Antibiotics and ultrasound-guided needle aspiration.
Should patients with mastitis continue breast feeding?
Yes, it helps avoid progression to abscess.
What are the symptoms of autoimmune hemolytic anemia?
Most often just fatigue and pallor after exposure to a medication or viral infection.
What is the treatment for autoimmune hemolytic anemia?
Glucocorticoids
Which class of medications is the most common cause of drug-induced immune hemolytic anemia?
Cephalosporins.
What condition is Lhermitte sign seen in?
Multiple sclerosis
What are the symptoms of optic neuritis?
Painful vision loss
What is the treatment for an acute exacerbation of multiple sclerosis?
High dose steroid such as methylprednisolone
In what condition can ophthalmoplegia be seen in an alcoholic?
Wernicke encephalopathy.
CSF analysis showing oligoclonal IgG bands supports what diagnosis?
Multiple sclerosis
What brain MRI findings support a diagnosis of MS?
Periventricular white matter lesions
Each unit of packed red blood cells raises hemoglobin by ____ and hematocrit by _____.
Each unit of packed red blood cells raises hemoglobin by 1g/dL and hematocrit by 3%.
For most patients, transfusion should be initiated for hemoglobin less than ___.
7g/dL
A unit of platelets will increase a patients platelet count by approximately how much?
50,000/microL
What is the appropriate ratio of red cells, platelets, and plasma in a massive transfusion protocol?
1:1:1.
Relief of pain associated with elevation of the affected testicle is known as what sign?
Phren sign
What is Phren sign associated with?
epididymitis
Where is pain typically located in epididymitis?
The posterolateral aspect of the testicle
What is the treatment for epididymitis in patients who do not have high risk sexual behavior?
A fluoroquinolone such as levofloxacin.
What is the treatment for epididymitis in patients with high risk sexual behavior?
Ceftriaxone and doxycycline
What is the first line medication for septic shock with hypotension?
Norepinephrine is the first line vasopressor
What does a plethoric inferior vena cava on ultrasound indicate in the setting of septic shock?
It means that the patient would not benefit from additional fluids
What is the first-line vasopressor or inotropic agent of choice for cardiogenic shock?
Norepinephrine. Although norepinephrine acts primarily on the vasculature to increase vascular tone, it is still the first recommended agent for cardiogenic shock.
What type of cord injury is characterized by complete loss of motor, pain, and temperature below injury, but retained proprioception and vibratory sensation?
Anterior cord syndrome
What are the most common mechanisms of injury for anterior cord syndrome?
Hyperflexion or vascular injuries
What cord syndrome is characterized by sensory and motor deficits greater in the upper extremities than the lower extremities?
Central cord syndrome
What is the most common mechanism of injury to cause central cord syndrome?
Forced hyperextension
What cord syndrome is characterized by ipsilateral loss of motor, vibratory sensation, and proprioception with contralateral loss of pain and temperature sensation?
Brown-Sequard syndrome
What is the most common mechanism of injury causing Brown-Sequard syndrome?
Penetrating trauma
What are the National Emergency X-Radiography Utilization Study (NEXUS) criteria for not obtaining imaging of the cervical spine in blunt trauma?
Imaging may be avoided if the patient does not have cervical midline tenderness, focal neurologic deficit, altered mental status, intoxication, or a distracting injury.
What is clicking rib syndrome?
A lower rib pain syndrome characterized by lower rib pain at the costal margin that is reproducible with palpation.
What signs and symptoms associated with chest pain are positive likelihood ratios for chostochondritis?
Pain worsens with breathing, movement, and horizontal arm flexion (crowing rooster maneuver).
Pain reproducible with palpation over the costochondral junctions
Papillary muscle rupture is associated with what type of MI?
Inferior MI
How long after MI do symptoms of papillary muscle rupture present?
3-5 days after infarction
What valvular disease occurs secondary to papillary muscle rupture?
Mitral regurgitation
What are the symptoms of mitral regurgitation?
Pulmonary edema, dyspnea, heart failure, and even cardiogenic shock.
What is the name of the tendinous structures that connect the mitral valve leaflets to the papillary muscle?
Chordae tendinae.
What shoulder injury presents with a “squared off” shoulder, slight shoulder abduction, and external rotation?
Anterior shoulder dislocation
What is a Hill-Sachs Lesion?
Posterolateral humeral head compression fracture
What is a Bankart lesion?
An avulsion of the glenoid labrum
Which nerve is most commonly injured in shoulder dislocations?
Axillary nerve.
What is the first line treatment for acute bacterial sinusitis?
Augmentin 875/125 BID
What is the first line pharmacotherapy and dose for SVT?
Adenosine 6mg rapid bolus, followed by 12mg if first dose is unsuccessful
What is the most common cause of a pleural effusion in a patient residing in a developing nation?
Tuberculosis.
Does pleural effusion cause increased or decreased tactile fremitus?
Decreased
What is the classic EKG finding of pericardial effusion?
Electrical alternans
What is the definitive therapy for pericardial effusion with tamponade?
Pericardiocentesis
What is the triad of symptoms associated with pericardial effusion?
Becks triad - hypotension, JVD< and muffled heart sounds
What is the most common cause of atraumatic pericardial effusion with tamponade?
Malignancy.
What is the most common cause of atypical pneumonia?
Mycoplasma pneumonia
What are the expected chest XR findings in atypical pneumonia?
Patchy infiltrates
What is the first line therapy for atypical pneumonia?
Macrolides of respiratory fluoroquinolones
Which electrolyte abnormality is seen in Legionella pneumonia?
Hyponatremia
What rash presents with golden crusted lesions?
Impetigo
What is the first line treatment for impetigo?
Mupirocin (or retapamulin)
What is the causative agent of impetigo?
Staph aureus (most common)
Can also be caused by strep
What renal complication may occur following impetigo?
Poststreptococcal glomerulonephritis.
Why would a patient with a medication-induced dystonic reaction develop airway compromise?
Laryngeal dystonia leading to airway obstruction.
What clinical feature is MOST suggestive of appedicitis?
Periumbilical pain that migrates to the right lower quadrant.
What is the treatment for acute appendicitis?
Appendectomy
What special tests would you preform on a patient in whom you expect appendicitis?
Check for McBurney point tenderness, Rovsing sign, Psoas sign, and Obturator sign.
Is appendicitis more common in men or women?
Appendicitis is more common in men and boys.
What is the most common cause of appendicitis?
Fecolith
What are the expected ultrasound findings in acute cholecysitis?
Pericholecystic fluid and gallbladder wall thickening greater than 4-5mm
What is a positive murphy sign?
Inspiratory pause or arrest with deep palpation of the right upper quadrant.
Where does acute cholecystitis cause referred pain?
The right shoulder
Fever, right upper quadrant pain, and jaundice suggest what pathology?
Ascending cholangitis.
What is the most likely diagnosis for asymmetric oligoarthritis 1-4 weeks following urethritis or enteric infection?
Reactive arthritis
What is the preferred imaging modality for aortic disection?
CTA of the aorta
What is the initial treatment for aortic dissection?
Aggressive BP control with a BB such as esmolol.
When might an aortic dissection cause stroke symptoms?
Dissection near the carotid artery
What are the systolic BP and HR goals for a patient with an aortic dissection?
SBP 120-100
HR <60
Why is lowering the heart rate, not only the blood pressure, also an important step in the management of aortic dissection?
Lowering the heart rate in aortic dissection decreases the potential propagation of the dissection flap by decreasing the shearing forces.
In patients with nephrolithiasis, when has medical expulsive therapy with tamsulosin been shown to be most effective?
When the stone size is less than 10 mm.
What are most kidney stones made of?I
Calcium oxalate
What would you be concerned about if a patient was found to have a struvite stone?
Infection - struvite is produced by urease-producing bacteria
Describe the typical patient in which you would find a kidney stone made of cystine.
A child with metabolic disease(s)
What is the most common cause of croup?
Parainfluenza virus
What is the treatment for croup?
Oral or IM dexamethasone, plus nebulized racemic epi for mod-severe cases.
What x-ray finding would likely be found in a croup patient?
Steeple sign
What is the oseltamivir dose for prophylaxis of influenza?
75mg PO QD X 7 days
What is the oseltamivir dose for treatment of influenze?
75mg PO BID x 5 days
T/F? Oseltamivir should only be started in patients with symptoms <2 days
False, high-risk outpatients should be treated with oseltamivir regardless of symptom duration.
Which antiviral medication is recommended for the treatment of influenza patients who are unable to tolerate oral oseltamivir?
Intravenous peramivir.
What is the most common bacteria causing infection after cat bites?
Pasturella multocida
What antibiotic should be prescribed for cat bites?
Augmentin
What characteristics of mammal bite wounds indicate that they should be closed primarily?
Injury to the face or scalp, presentation within six hours, and no host immunosuppressive conditions.
What technique may improve the chance of diagnosing a Lisfranc injury on plain radiograph?
Including weight-bearing (stress) views.
What medication can be given to non-pregnant patients with abnormal uterine bleeding to slow the bleeding?
IV estrogen
What are the 4 structural causes of abnormal uterine bleeding?
Polyp
Adenomyosis
Leiomyoma
Malignancy/hyperplasia
What are the 5 non-structural causes of abnormal uterine bleeing?
Coagulopathy Ovulatory dysfunction Endometrial Iatrogenic Not yet classified
What medication is used to treat postpartum hemorrhage due to atony?
Misoprostol
Oral contraceptives are absolutely contraindicated in smokers over what age?
35 years.
A holosystolic murmur with radiation to the axilla describes what type of murmur?
Chronic mitral regurg
Name two diastolic murmurs.
Mitral stenosis and aortic insufficiency.
A patient has epigastric pain radiating to the back. A chest XR shows free air under the diaphragm. What is the most likely diagnosis?
Perforated peptic ulcer
What is the first and second most common cause of peptic ulcer disease?
First - H. pylori
Second - Aspirin or NSAID use
How long after acute injury is compartment syndrome typically seen?
Between two hours and 6 days post injury
What is the classic physical exam finding in compartment syndrome?
Pain out of proportion to physical exam findings
What is normal compartment pressure?
10-12mmHg
What is the delta pressure when using a tonometer?
Delta pressure greater than ___ should get a fasciotomy.
Delta pressure is diastolic blood pressure - intracompartmental pressure.
Delta pressure >/= 30 probably needs a fasciotomy
What are the 6 P’s of compartment syndrome?
Paresthesia Pallor Pulselessness Poikilothermia Paralysis Pain out of proportion
Compartment syndrome of the deep posterior compartment of the lower leg will lead to which passive movement producing intense pain?
Toe extension.
Blood in the anterior chamber of the eye is known as a?
Hyphema
What can you do for a patient with a hyphema while waiting for ophthalmology consult?
Elevate the head of the bed to 45 degrees to promote settling of blood and prevent occlusion of the trabecular meshwork
Explain the grading system for hyphema.
Grade I = <1/3 anterior chamber volume
Grade II = 1/3-1/2 anterior chamber volume
Grade III = >1/2 anterior chamber volume
Grace IV = Total anterior chamber volume
What disease are spontaneous hyphemas commonly associated with?
Sickle cell disease.
C5 radiculopathy would effect what finger(s)?
None
C6 radiculopathy would effect what finger(s)?
Thumb
C7 radiculopathy would effect what finger(s)?
2nd and 3rd digits
C8 radiculopathy would effect what finger(s)
4th and 5th digits
What is Lhermitte phenomenon?
Shock-like paresthesias that occur with neck flexion. This can be a sign of compression of the spinal cord from a midline disk herniation or spondylosis.
What rhythm is characterized by a sawtooth pattern?
A flutter
What is the treatment for rate control of rapid atrial flutter in a stable patient?
A non-dihydropyridine calcium channel blocker or a beta-blocker.
What are some risk factors for the development of plantar fasciitis?
Obesity, prolonged standing or jumping, and flat feet.
A westermark sign seen on chest XR is specific for what?
Pulmonary embolism
What are some abnormalities that may be seen on chest XR in a patient with CHF?
Kerley B lines
Increased cardiac silhouette
Increased interstitial and alveolar edema
Peribronchial cuffing
What causes Kerley B lines on chest X-ray?
Engorgement of lymphatic vessels.
What tests can be used to diagnose mononucleosis?
Mono-spot or herterophile antibody test
Between strep and mono, which classically has anterior cervical LAD and which has posterior cervical LAD?
Strep - anterior
Mono - posterior
What organomegaly is concerning during mononucleosis?
Splenomegaly
What medications will cause a rash if given to a patient with mononucleosis?
Amoxicillin or ampicillin
When is the false-negative rate highest for the heterophile antibody test?
During the first week of symptoms.
What CBC and blood smear findings are common in mononucelosis?
Left shift and atypical lymphocytes.
What is the mechanism of action of lactulose and rifaximin in treating hepatic encephalopathy?
Lactulose acidifies gut contents and causes a loss of NH4+ in the stool, and rifaximin is an antibiotic against colonic flora that produce ammonia.
What is the most common valve affected by infectious endocarditis?
Mitral valve
What is the most common valve involved in infective endocarditis in IV drug users?
Tricuspid valve
What is the most common pathogen causing infective endocarditis in all populatuions?
Staph aureus
What is a reasonable empiric therapy for suspected infective endocarditis?
Vancomycin plus gentamycin
What variant of endocarditis is found in patients with systemic lupus erythematosus?
Libman-Sacks endocarditis, a noninfectious (sterile) thrombotic form of endocarditis.
What physical exam findings are suggestive of infective endocarditis?
FROM JANE
Fever
Roth spots
Osler nodes
Murmur
Janeway Lesions
Anemia
Nailbed hemorrhages (splinter hemorrhages)
Emboli
What neurovascular structure is most frequently injured with a tibiofemoral dislocation?
Peroneal nerve
Popliteal artery is the most common artery injury
What is the ankle-brachial index?
The ratio of the systolic blood pressure at the ankle compared to the systolic brachial pressure. An ABI of < 0.9 is considered abnormal.
What is the most common type of knee dislocation?
Anterior knee dislocation (tibia is displaced anteriorly relative to the femoral condyle)
What is the primary treatment intervention for a patient with sickle cell anemia who presents to the emergency department with an acute ischemic stroke?
Transfusion therapy.
What is the most common cause of SJS and TEN?
Drugs - PEC SLAPP
Penicillin
Ethosuximide
Carbamazepine
Sulfa Lamotrigine Allopurinol Phenytoin Phenobarbital
What is the second most common cause of SJS and TEN?
Mycoplasma pneumoniae infections
Name two disorders other than SJS/TEN that have a positive Nikolsky sign.
Pemphigus vulgaris and staphylococcal scaleded skin syndrome
Why is ipratropium bromide not used while hospitalized?
It is shown to reduce hospitalization rate but not hospitalization duration.
What is the blood supply to anterior nosebleeds?
Posterior?
Anterior - Kiesselbach Plexus
Posterior - Sphenopalatine artery
What is included in the initial management of an anterior nosebleed?
Vasoconstrictive medications such as oxymetazoline or phenylephrine, and pressure.
How long should packing remain for the treatment of an anterior nosebleed?
48 hours
How can you tell the difference between an incarcerated hernia from a strangulated hernia?
Strangulated hernias have necrosis and overlying skin changes.
Patients with strangulated hernias also often have elevated white count and/or lactate.
What is the treatment for a strangulated hernia?
IV cefoxitin and emergent surgery consult
What is the difference between a direct and an indirect inguinal hernia?
Direct passes directly through a defect in the transversalis fascia, whereas indirect passes through a patent processus vaginalis in the inguinal ring.
How much water should a patient with a detected kidney stone drink within the first 24 hours?
2 L.
What is quadruple therapy for H pylori consist of?
Bismuth
Metronidazole
Tetracycline
Omeprazole
What is triple therapy for H pylori?
Omeprazole, clairithromycin, and amoxicillin
How many patients infected with H. pylori will develop an ulcer?
5–10%.
Are gastric ulcers or duodenal ulcers more common?
duodenal
What lead are R and R’ waves seen in in a left bundle branch block?
Right bundle branch block?
R and R’ (bunny ears) are seen in V6 in a left BBB.
They are seen in V1 in a right BBB
What are causes of left bundle branch block?
Myocardial ischemia, myocardial infarction or myocarditis, but most often is caused by the degeneration of the conduction system with age.
What is the most common cause of osteomyelitis in children?
Staph aureus
What bacteria may cause osteomyelitis in patients who have a history of sickle cell disease?
Salmonella.
A pregnant patients pelvic ultrasound shows a psuedosac with surrounding free fluid. What is this concerning for?
Ectopic pregnancy
What is the most common site of implantation for ectopic pregnancy?
The ampulla of the fallopian tube.
What is the most accepted hCG discriminatory zone for visualizing an intrauterine pregnancy on transvaginal ultrasound?
1,500 IU/L.
What is the most common cause of bronchiolitis?
RSV
What is the first step in management for a child with bronchiolitis?
Nasal suctioning
In what age group does bronchiolitis primarily occur in?
Children < 2
Bronchiolitis is most common during what time of the year?
In North America, bronchiolitis has a peak occurrence between November and March.
What is the preferred treatment for a peritonsillar abscess?
Drainage by needle aspiration and augmentin or clindamycin.
What are the CENTOR criteria for streptococcal pharyngitis?
Absence of cough, tonsillar exudates, fever, and tender anterior cervical lymphadenopathy.
What are the causes of central diabetes inspididus?
Head trauma, congenital, and genetic disorders
What is the most appropriate first line treatment for minor bleeding in patients with von Willebrand disease?
Desmopressin
What is the role of von Willebrand factor?
Assists with platelet adhesion and is a carrier for factor VIII
What is the treatment for severe bleeding in a patient with von Willebrand disease?
recombinant von Willebrand Factor
or cryoprecipitate
What additional medication can help decrease menorrhagia in patients with von Willebrand disease?
Oral contraceptives.
What is the treatment for acute bacterial parotitis?
Ampicillin/sulbactam
or
nafcillin + metronidazole or clindamycin
What is the most common pathogen associated with acute bacterial parotitis?
Staph aureus
What antibiotic is appropriate for a pediatric patient with bacterial parotitis and a severe penicillin allergy?
Clindamycin.
What is the treatment for a-fib with RVR?
Beta blocker or CCB
In underdeveloped countries, what underlying disease is most frequently associated with atrial fibrillation?
Rheumatic heart disease.
A patient with a lithium level greater than ____ should be considered for dialysis.
> 5 mEq/L
or >4mEq/L in the setting of impaired renal function
True or false: activated charcoal is effective in binding lithium.
False, lithium is a metal, therefore, activated charcoal will not be effective, as it does not bind metals.
Name 4 special tests to evaluate an ankle injury.
Squeeze test - syndesmotic sprain
Anterior drawer - anterior displacement of talus on tibia
External rotation test -
Talar tilt test -
What are the structures injured in lateral ankle sprain?
Anterior talofibular ligament, calcaneofibular ligament, and posterior talofibular ligament.
What are the 5 components of management of acute COPD exacerbation?
Beta-adrenergic agonists (albuterol)
Anticholinergic agents (Ipratropium)
Oral glucocorticoid therapy (prednisone)
Noninvasive positive pressure ventilation
Antibiotics (for moderate to severe exacerbations, azithromycin or augmentin are good choices)
True or false: intravenous corticosteroids have been shown to be superior to oral corticosteroids in the management of an acute COPD exacerbation.
False.
What is the first line medication, concentration, and instructions for a scabies infection?
Permethrin 5% cream on day 1, then reapply in 1 week.
In what type of scabies are thousands of mites present?
Crusted or Norwegian scabies.
What is the most common risk factor for new-onset childhood immune thrombocytopenia?
Viral infection.
Reduced factor VIII activity level is found in what bleeding disorder?
Hemophilia A
What is the most likely diagnosis in a patient with painless BRBPR and constipation?
Diverticulosis
What electrolyte abnormality is commonly seen in hypothyroidism?
Hyponatremia.
List 3 types of definitive airway?
Orotracheal tube, nasotracheal tube, surgical airway
What antibiotic is used for infection prophylaxis before surgery?
Cefazolin
What is the antibiotic regimen of choice if an open fracture is deemed to be large (> 10 cm) or very contaminated?
First-generation cephalosporin and gentamicin.
If a child under one year of age aspirates a foreign body and is choking, what is the appropriate management?
Holding the head lower than the feet, alternate five back blows with five chest thrusts.
What imaging should be ordered to detect a foreign body aspiration that is not radiopaque?
lateral decubitus chest XR - it will detect air trapping. If you hear wheezing on right, do a right lateral decubitus, on left, left lateral decubitus.
What disease is associated with urinary incontinence, ataxia, and dementia?
Normal pressure hydrocephalus.
What special test has the highest sensitivity for sciatica?
What about specificity?
Sensitivity - straight leg raise
Specificity - crossed straight leg raise
A patient with sciatica and weakness with toe extension likely has compression of what nerve root?
L5.
Does unstable angina have any EKG changes or troponin elevation?
Neither
How long can an elevated troponin level be detected after acute myocardial infarction?
Up to seven days.
What nerve injury is most common with a fibular head fracture?
Common peroneal nerve injury
What are the expected BUN:Cr ratios for pre-renal, intrarenal, and post-renal causes of renal failure?
Pre-renal = BUN:Cr >20 Intrarenal = BUN:Cr<10:1 Post-Renal = BUN:Cr 10-20:1
What is an extraintestinal manifestation of celiac disease?
Dermatitis herpetiformis
What is an extraintestinal manifestation of inflammatory bowel disease?
Ankylosing spondylosis
Pernicious anemia is a type of selective malabsorption leading to a deficiency in what vitamin?
Vitamin B12 (cobalamin).
Orthostatic hypotension can be diagnosed by a decrease in SBP by how much when going from sitting to standing?
DBP?
Fall >20 SBP
Fall >10 DBP
Which is the more common finding in volume-depleted adults: hypokalemia or hyperkalemia?
Hypokalemia.
Is a Wenckebach heart block Mobitz I or Mobitz II?
Mobitz I
Describe the PR interval and QRS complexes in a Wenckeback heart block. (Mobitz I)
Progressively longer PR interval until a QRS is dropped.
Describe the PR intervals and QRS complexes in a Mobitz II block.
Regular PR interval with random dropped QRS complexes.
Describe the P waves and QRS complexes in a complete heart block?
P waves and QRS complexes march out, but QRS complexes have no releation to P waves.
What does a notched P wave on ECG potentially indicate?
Left atrial enlargement.
What is the characteristic EKG finding of WPW?
Delta waves
What is the treatment for a tension pneumothorax?
Needle thoracostomy
What are the physical exam findings of a tension pneumothorax?
Diminished breath sounds, distended neck veins, hypotension, and tracheal deviation.
In what other location can needle decompression be performed if unable to reach the pleura from the anterior midclavicular space?
Fourth or fifth intercostal space in the midaxillary plane may also be used (the same location as tube thoracotomies).
What is an appropriate treatment plan for a patient with HOCM with a syncopal episode?
Admission and cardiology consult
What is an appropriate treatment plan for a patient with HOCM found incidentally who has no symptoms?
Outpatient cardiology follow up
Describe the murmur associated with HOCM.
Harsh crescendo-decrescendo systolic murmur that increases intensity with valsalva and decreases with squatting.
What is the appropriate dosing of heparin in ST elevation myocardial infarction patients?
A 60 units/kg bolus (up to 4,000 units) followed by a 12 units/kg/hr infusion (up to 1,000 units/hr).
What is the initial treatment for acute angle closure glaucoma?
A topical beta blocker and alpha agonist, such as timolol and apraclonidine, along with acetazolamide.
You’ve diagnosed a patient with acute angle closure glaucoma and ophthalmology is on the way. You’ve treated the patient with timolol, apraclonidine, and acetazolamide, and a recheck of IOP is 50 mmHg. What is the next appropriate treatment?
IV mannitol
A FOOSH injury with snuffbox tenderness is concerning for what injury?
Scaphoid fracture
What is an appropriate splint for a scaphoid fracture?
Thumb spica splint
What is the most concerning complication for scaphoid fractures?
AVN of the proximal pole of the scaphoid.
What type of hypersensitivity reaction is contact dermatitis?
Type IV.
What is the dose of atropine in symptomatic bradycardia with a pulse?
1 mg IV push.
Which three chemicals should not be treated with immediate water irrigation if splashed into the eye because of their harmful exothermic effects?
Dry lime; elemental metals, such as sodium, potassium, magnesium, phosphorus, lithium, cesium, and titanium tetrachloride; and phenol.
What is the goal pH of the eye after irrigating a chemical burn?
7.0-7.5
What is worse, acid or alkaline chemical burn of the eye?
alkaline - penetrates deeper and faster.
What type of chemical burns to the eye cause liquefaction necrosis, and what type cause protein coagulation?
Liquefaction necrosis - alkaline burns
Protein coagulation - acidic burns
What is the normal range of intraocular pressures?
10 to 20 mm Hg.
What mechanism is the main cause of acute angle closure glaucoma?
Obstruction of the aqueous humor outflow (trabecular meshwork)
What types of hepatitis are transmitted by fecal-oral contamination?
A and E (The vowels hit your bowels)
What hepatitis is dependent on hep B coinfection?
Hep D
What laboratory value will be decreased (aside from hemoglobin or hematocrit) in an acute episode of hemolytic anemia?
The haptoglobin level as it scavenges free hemoglobin released by lysed red blood cells.
When should hypertension be treated in the setting of an acute ischemic stroke?
If the systolic is greater than 220 mmHg, the diastolic is greater than 110 mmHg, or if the patient has another condition that would benefit from blood pressure control.
What laboratory test can help differentiate between acute heart failure and an exacerbation of chronic obstructive pulmonary disease in a dyspneic patient?
Brain natriuretic peptide.
What is the most common cause of small bowel obstruction?
Adhesions
What are the first two steps of treating a small bowel obstruction?
Keeping patient NPO and placing a NG tube
What type of hernia is most commonly associated with small bowel obstruction?
Inguinal hernia.
What is the best benzodiazepine to give for status epilepticus?
Lorazepam
What is the best benzodiazepine for treatment of status epilepticus in a patient without intravenous access?
IM midazolam
What is the most oikely diagnosis for a patient in respiratory distress with bilateral rales, tachypnea, tachycardia, and a high pitched blowing murmur occurring after S2 is heard best along the left sternal border in the third intercostal space?
Aortic regurgitation
True or false: increases in blood pressure worsen aortic regurgitation.
True. Tachycardia and afterload reduction will reduce regurgitation, whereas slower heart rates and increases in afterload will worsen the regurgitation.
What is the innervation of the biceps muscle?
The musculocutaneous nerve. The nerve roots for the musculocutaneous nerve are C5, C6, and C7.
What is the classic ECG finding in de Winter syndrome?
J point depression with a sloping ST segment into a peaked, hyperacute T wave in the precordial leads. This suggests a complete LAD occlusion and should be treated as an ST elevation myocardial infarction equivalent.
What is Wellens syndrome?
Critical stenosis of the LAD with either biphasic t waves or deeply invereted t waves.
What is the appropriate empiric treatment for urethritis in a male with two new sexual partners?
Ceftriaxone 500mg IM and doxycycline 100mg BID x 7 days
True or false: Chlamydia trachomatis is identified on Gram stain as gram-negative diplococci.
False. Chlamydia is a small gram-negative bacterium that is an obligate intracellular parasite as it can only replicate within a host cell.
What is gonorrhea reported as on a gram stain?
Gram negative diplococci
What is the first line treatment of severe hypertension in the setting of an acute MI?
Nitroglycerine
What is the first line treatment of severe hypertension in the setting of aortic disection?
Esmolol
What is the first line treatment of severe hypertension in the setting of eclampsia?
Magnesium sulfate
What is the first line treatment of severe hypertension in the setting of a hypertensive encephalopathy?
Nicardipine
True or false: Focal deficits resulting from hypertensive encephalopathy may present on opposite sides of the body.
True. Focal deficits do not follow an anatomic pattern and may be present on opposite sides of the body`
An EKG shows a rate of 160, irregularly irregular, with 3 different P wave morphologies. What is the most likely diagnosis?
Multifocal atrial tachycardia.
What is the treatment for multifocal atrial tachycardia?
Treat underlying cause, do not give rate-limiting medications.`
What is an appropriate treatment for a patient with a fib with RVR?
IV diltiazem
What is an appropriate treatment for rhythm control for tachydysrhythmias?
procainamide
What is considered a safe time period for cardioversion in new-onset atrial fibrillation or atrial flutter?
48 hours.
Describe the murmur of mitral valve prolapse.
Late systolic crescendo murmur
What is the most common ultrasound finding in a patient with ovarian torsion?
Ovarian enlargement due to venous and lymphatic engorgement.
What is the whirlpool sign?
What is it highly specific for?
Whirlpool sign is the presence of coiled vessels on ultrasound of an ovary which is nearly 90% accurate in diagnosing ovarian torsion.
What is the treatment for purulent cellulitis vs non-purulent cellulitis?
Purulent cellulitis should be covered for MRSA, with doxycycline, bactrim, clindamycin, or linezolid.
Non-purulent cellulitis can be treated with cephalexin, amoxicillin, or dicloxacillin
What is the most common pathogen implicated in erysipelas?
Beta-hemolytic streptococci.
Is diarrheal onset or emesis onset more likely to be a bacterial cause of gastroenteritis?
Diarrheal onset
Which pathogen is most responsible for infantile malnutrition from persistent diarrhea in low-resource countries?
Shiga toxin-producing enteropathogenic Escherichia coli.
Progressive encephalopathy with hepatic dysfunction is characteristic of what syndrome?
Reye syndrome
What is the biggest risk factor for Reye syndrome?
Salicylate use
Is WPW with a wide QRS orthodromic or antidromic?
Antidromic
What are the only two appropriate treatments for antidromic WPW?
Procainamide or cardioversion
What is the triad of EKG changes in WPW?
Slurred upstroke of QRS complex (delta wave)
Wide QRS
Short PR interval
What class of antiarrhythmics does procainamide belong to
Class 1a.
What type of organisms are asplenic patients high risk for contracting infections from?
encapsulated organisms
What are the most common organisms to cause sepsis in asplenic patients?
Strep pneumo, Neisseria meningitidis, and H. influenzae.
also consider salmonella, although it is not as common
Name 7 encapsulated bacteria.
SHiNE SKiS Strep pneumo H. influenzae (type B) Neisseria meningitidis E. coli
Salmonella typhi
Klebsiella pneumoniae
Streptococcus (group B)
What common viral illness puts a patient at risk for splenic injury and rupture?
Epstein-Barr virus infection.
What is the appearance of PJP on chest XR?
Bilateral interstitial infiltrates. (bat wing apperance)
What is the treatment for PJP?
TMP-SMX
What lab findings are associated with PJP?
CD4 <200
Increased LDH
What is the most common cause of aortic stenosis?
Calcific dengeration
Describe the murmur assocaited with aortic stenosis.
systolic Crescendo-decrescendo murmur that radiates to the carotids
What is the only cardiac valve that has two cusps instead of three?
Mitral valve.
Episodic vertigo, sensorineural hearing loss, and tinnitus is characteristic of?
Meniere disease
What is the treatment for meniere disease?
avoidance of alcohol, caffeine, stress, sodium, MSG, and nicotine
Benign paroxysmal positional vertigo (BPPV) is thought to be caused by what?
BPPV is most commonly attributed to calcium debris within the posterior semicircular canal but may also occur in the lateral and anterior semicircular canals.
What is the most likely diagnosis for a patient presenting with painless visual disturbances, floaters, flashing lights, and a curtain-lowering sensation to his vision?
Retinal detachment.
Describe the “classic” pseudotumor cerebri (idiopathic intracranial hypertension) patient.
A young woman with obesity.
What are the symptoms of psuedotumor cerebri?
intermittent visual changes, headache, and pulsatile tinnitus.
What are the hallmark findings in pseudotumor cerebri?
Papilledemia, elevated opening pressure on lumbar puncture.
What is the treatment for pseudotumor cerebri?
Low sodium diet, weight loss, acetazolamide, optic nerve sheath fenestration, shunt.
What is an alternative to funduscopy when evaluating for papilledema?
Ocular ultrasound.
True or false: positive birefringence on crystal analysis is consistent with gout.
False
What is the most common presentation of Hodgkin lymphoma in a 17-year-old boy?
Painless cervical LAD
Does hodgkin or non-hodgkin lymphoma have reed-sternberg cells?
Hodgkin
What are the two methods of reducing a nursemaids elbow?
Supination and flexion or hyperpronation
What is the best initial diagnostic test for a suspected pheochromocytoma?
24-hour urine fractionated metanephrine and catacholamine level or a plasma fractionated metanephrine.
What is a pheochromocytoma?
A neoplasm of the chromaffin cells within the adrenal medulla.
What is the treatment for hypertension in the setting of pheochromocytoma?
An alpha blocker (phenoxybenzamine is preferred) and then a beta blocker after an alpha blockade has been established.
What is the triad of symptoms for pheochromocytoma?
Episodic headache, diaphoresis, and tachycardia with hypertension.
What is the most common cause of a transient aplastic crisis in a sickle cell patient?
A recent parvovirus B19 infection
What is the most common complication from a midshaft humeral fracture?
Radial nerve injury
What neurological findings are consistent with radial nerve injury after a midshaft humeral fracture?
Wrist drop, loss of extension of fingers, thumb, and wrist
What is an alternative agent for the treatment of PJP pneumonia?
Pentamidine.
What is the most common cause of DIC?
Infection.
Which ACL physical exam test provides the best sensitivity and specificity for ACL rupture?
The Lachman test.
What is the technique to detorse a testicular torsion?
Medial to lateral rotation
What is the most appropriate test to diagnose a bile leak status post cholecystectomy?
Hepatic iminodiacetic acid (HIDA) scan.
HIV and antiretroviral therapies can cause what cardiovascular disorder?
Dilated cardiomyopathy
What is the cause of Chagas disease, the leading cause of dilated cardiomyopathy in Central and South America?
A protozoan infection with Trypanosoma cruzi.
What is the first line treatment for candidal balanitis?
Topical clotrimazole cream
What type of medication is chlordiazepoxide?
benzodiazepine
Which frequently used benzodiazepine is unaffected by hepatic metabolism status?
Lorazepam. In contrast, diazepam, midazolam, and chlordiazepoxide all undergo significant hepatic metabolism, which can result in accumulation of parent drug and associated prolonged drug effects in those with impaired liver function.
A radial/ulnar wrist facture with dorsal displacement is known as a ______ fracture.
Colles (dinner fork deformity)
A radial/ulnar wrist facture with ventral displacement is known as a ______ fracture.
Smith (garden spade deformity)
