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EOR Exams > Emergency Medicine EOR Exam Cards > Flashcards

Emergency Medicine EOR Exam Cards Flashcards

1
Q

Presentation of Acute bacterial endocarditis

A

Fever
Often IVDU
New systolic heart murmur (regurg)

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2
Q

Causitive agents of bacterial endocarditis

A

Acute - S. aureus
Subacute - S. viridans

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3
Q

3 Major Dukes criteria for bacterial endocarditis

A

Vegetation on Echo
2 blood cultures 12 hours apart
New regurg murmur

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4
Q

Difference of causitive agent and vegetated valve for IVDU v. non-IVDU in bacterial endocarditis

A

Drug users: Staphylococcus w/ tricuspid veggies
Non-drug users: Streptococcus w/ mitral veggies

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5
Q

4 Minor DUke criteria

A

Risk factor,
Fever 100.5,
Vascular phenomena (splinter hemorrhages, Janeway lesions: painless, palms and soles), Immunologic phenomena (Osler node: raised painful tender; Roth spots: exudative lesions on the retina)

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6
Q

Management for bacterial endocarditis including prosthetic valve and prophylaxis for procedures

A

IV vancomycin or ampicillin/sulbactam PLUS aminoglycoside
Prosthetic valve: Add rifampin
High-Risk patients prophylaxis for procedures: Amoxicillin

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7
Q

Presentation and management of stable angina

A

Predictable pain relieved by rest or NTG
ST depression of 1mm+ on stress test
Agiography for Ddx
Beta blockers and NTG to treat, angioplasty if severe

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8
Q

Presentation of unstable angina

A

Previously stable and predictable symptoms of angina that are now more frequent, increasing, or present at rest

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9
Q

Diagnosis and mangement of unstable angina

A

Admit for continuous cardiac monitoring
Stress test if symptoms resolve
MONA
Antiplatelet, BB, LMWH

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10
Q

Presentation and management of prinzmetal angina

A

Smoking is #1 risk factor, cocaine abuse also risk factor
May see U waves
No reduction in exercise capacity
Transient ST elevation

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11
Q

Management for prinzmetal angina

A

Stress test or heart cath (no clot found)
IV nitrates
Propranolol = Contrindicated
CCB and long acting nitrates to treat

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12
Q

Common complaints for heart arrhythmias

A

SOB and Chest Pain

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13
Q

Premature atrial contractions

A

Early P waves - may not have a QRS

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14
Q

Atrial fibrillation

A

Irregular heart rate with many foci leading to irregular P waves

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15
Q

Atrial flutter

A

One foci, sawtoothed P waves between QRS complexes. More regular than A fib

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16
Q

Paroxysmal supraventricular tachycardia

A

Regular, fast (160 to 220 beats per minute) heart rate that begins and ends suddenly and originates in atria

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17
Q

Accessory pathway tachycardia

A

An accessory pathway is an additional electrical conduction pathway between two parts of the heart most common is WPW. The impulse from the SA node takes an accessory pathway to the AV node and can result in tachycardia. Shorten PR interval <.20

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18
Q

AV nodal reentrant tachycardia

A

Most common type of supraventricular tachycardia.
Heart rates 100-250 bpm regular rhythm Late P waves - may be hidden within the QRS

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19
Q

Management of narrow tachycardic arrhythmias

A

Slowed up with either calcium channel blockers or beta-blockers, adenosine, procainamide, or cardioversion

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20
Q

Management for Wide tachycardic arrhythmias

A

Cardioversion or amiodarone

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21
Q

Becks triad for cardiac tamponade

A

Hypotension
Muffled heart sounds
JVD

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22
Q

Other signs of cardiac tamponadeq

A

Pulsus alternans
Pulsus paradoxus (large drop in BP ~10mmHg with inspiration)

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23
Q

Dx and management of cardiac tamponade

A

Echo showing diastolic collapse of the right ventricle (an effusion will NOT show collapse)
Pericardiocentesis to treat

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24
Q

5 emergent causes of chest pain

A

Pericarditis
ACS/MI
PE
Pneumothorax
Aortic Aneurism/Dissection

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25
Q

5 tests to order for chest pain

A

EKG
Troponin I
BNP
CXR
CBC/CMP

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26
Q

Definition of ventricular tachycardia

A

Three or more consecutive VPBs, displaying a broad QRS complex tachyarrhythmia

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27
Q

EKG of a LBBB

A

Bunny ears in V4-6
On side of block

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28
Q

EKG of RBBB

A

Bunny ears in V1-3
On side of block

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29
Q

Presentation of an NSTEMI

A

Elevated troponins WITHOUT ST elevation or Q waves
Subendocardial infarct without complete blockage

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30
Q

Troponin as a cardiac biomarker

A

Most sensitive and specific, appears at 2-4 hours, peaks at 12-24 hours, and lasts for 7-10 days

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31
Q

CK-MB as a cardiac biomarker

A

Appears at 4-6 hours, peaks at 12-24 hours, and returns to normal within 48-72 hours

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32
Q

Myoglobin as a cardiac biomarker

A

Less commonly used appears at 1-4 hours. The peak is 12 hours and returns to baseline levels within 24 hours

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33
Q

Management for NSTEMI

A

Beta Blockers + NTG + aspirin and clopidogrel + heparin + ACEI + statins + reperfusion
NO thrombolysis
Less time sensitive than a STEMI

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34
Q

How a STEMI is different from an NSTEMI

A

Full thickness infarct with ST elevation/q waves along with biomarker elevation

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35
Q

EKG finding for anterior MI

A

Q waves and ST elevation in leads I, AVL, and V2 to V6

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36
Q

EKG finding for inferior MI

A

Q waves and ST elevation in leads II, III, and AVF

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37
Q

EKG finding for lateral MI

A

ST elevation in the lateral leads (I, aVL, V5-6). Reciprocal ST depression in the inferior leads (III and aVF)

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38
Q

EKG findings for posterior MI

A

ST depressions in V1 to V3

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39
Q

Time windows for STEMI PCI and Thrombolytics

A

Give ASA and Plavix immediately
PCI - 90 minutes
THrombolytics - 30 minutesif PCI not available

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40
Q

6 Absolute contraindications to thrombolytic use for an MI

A

Prior intracranial hemorrhage (ICH)
Known structural cerebral vascular lesion.
Known malignant intracranial neoplasm.
Ischemic stroke within 3 months.
Suspected aortic dissection.
Active bleeding or bleeding diathesis (excluding menses)

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41
Q

6 Cardiac Causes of DOE

A

Coronary heart disease
Heart failure
Myocarditis
Pericarditis
MI
ACS

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42
Q

8 Pulmonary causes of DOE

A

Asthma
COPD
Pneumonia
Pulmonary Hypertension
Obesity, kyphosis, scoliosis (restrictive lung disease)
Interstitial lung disease
Drugs (e.g., methotrexate, amiodarone) or radiation therapy, cancer
Psychogenic causes

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43
Q

6 potential causes of edema

A

CHF
Kidney disease
Liver disease
Chronic venous disease
Pregnancy
Drugs
Travel

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44
Q

Four treatments for edema

A

Reduce salt intake
Lasix HTCZ
Compression stockings
Body position (elevate legs)

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45
Q

2 medications that may cause edema

A

CCB
Alpha 1 blockers -zosin (ie. doxazosin, prazosin…)

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46
Q

Presentation of heart failure

A

DOE and then with rest
Chronic non-productive cough after lying down
Fatigue
Orthopnea
Nocturnal dyspnea
Nocturia

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47
Q

SIgns of heart failure

A

Cheyenne stokes breathing (cyclic)
Edema
Rales
S3/S4
JVD
Cyanosis/coolness
Ascites

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48
Q

Diagnostics for CHF

A

Elevated BNP (lower in obese)
Kerley B lines on CXR
Echo is BEST TEST

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49
Q

NYHA heart classes

A

I - No limitation
II - Slight limitation
III - Marked limitation
IV - Dyspnea at rest

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50
Q

Management for systolic CHF

A

HFrEF
ACEI
BB
LOOP DIURETIC

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51
Q

Management for diastolic HF

A

HfpEF
NO LOOP DIURETIC
ACEI and BB/CCB

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52
Q

Definition and management of hypertensive urgency

A

BP 180/120+ Without end organ damage
Immediate reduction not needed - start on 2 drug regimen with outpatient follow up

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53
Q

8 Indications of end organ damage (meaning hypertensive emergency)

A

Retinal hemorrhages
Papilledema,
Encephalopathy,
Acute and subacute kidney injury,
Intracranial hemorrhage,
Aortic dissection,
Pulmonary edema,
Unstable angina or MI

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54
Q

General management of hypertensive emergency

A

Reduce BP in first hour by 10-20% and then and additional 5-15% over the next 23 hours
Targets are Under 180/120 in first hour
and under 160/110 in the next 24 hours

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55
Q

Drug of choice for hypertensive urgency

A

Clonidine

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56
Q

Drug of choice for hypertensive emergency

A

Sodium nitroprusside

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57
Q

Indication to reduce BP to 140 in the first hour

A

severe preeclampsia, eclampsia, or pheochromocytoma crisis

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58
Q

Indication to reduce BP to 120 in first hour

A

Aortic DIssection

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59
Q

Drug of choice for hypertensive retinopathy

A

Clevidipine or Sodium Nitroprusside

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60
Q

Presentation and management of hypotension

A

Altered mental status, SBP under 90
Capillary wedge pressure over 15
Fluid and pressors

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61
Q

Definition and management of orthostatic hypotension

A

A drop of > 20 mm Hg systolic, 10 mmHg diastolic, 15 BPM increase in pulse 2-5 minutes after a change from supine to standing

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62
Q

Indication the orthostatic hypotension is due to low blood volume

A

Associated with HR increase >15 BPM

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63
Q

7 causes of orthopnea:
3 Cardiac
2 Pulm
2 Other

A

Cardiac causes:
CHF
MI
Arrhythmias (atrial fibrillation)

Pulmonary causes:`
COPD and cor pulmonale
Pulmonary hypertension

Kidney/Liver failure
Obesity

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64
Q

Arrhythmias causing palpitations - 3

A

Atrial fibrillation
Wolff-Parkinson-White (WPW) syndrome
Paroxysmal supraventricular tachycardia

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65
Q

Other cardiac conditions causing palpitations - 3

A

Sick sinus syndrome
MVP
MI

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66
Q

Endocrine and metabolic causes of palpitations - 4

A

Hypokalemia or Hypomagensemia
Hyperthyroid
Pheochromocytoma
T1DM Hypoglycemia

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67
Q

Drugs causing palpitations - 3+6

A

Cocaine
Amphetamines
Caffeine
(digoxin, beta-blockers, calcium channel antagonists, hydralazines, diuretics, minoxidil)

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68
Q

Pericardial effusion presentation

A

Similar to paricarditis with low voltage EKG, electrical alternans, and distant heart sounds
Relieved when sitting forward
Worsens with inspiration
Fluid on Echo
Treat with pericardiocentesis if large

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69
Q

Presentation of peripheral vascular disease

A

Hair loss, pallor, cyanosis, brittle nails, black dray ulcers. Hx of atherosclerosis

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70
Q

Diagnostics of peripheral vascular disease

A

ABI <0.9
Angiography is GOLD STANDARD

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71
Q

Definitive treatment for peripheral vascular disease

A

Arterial bypass

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72
Q

Medication for peripheral vascular disease

A

Cilostazol
Aspirin
Plavix
Statins

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73
Q
A
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74
Q

Syncope - primary cause and technical definition

A

Not enough blood to brain
Out for seconds with no resuscitation
Loss of postural tone and consciousness

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75
Q

Workup for syncope vs. presyncope

A

SAME WORKUP

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76
Q

Differential and workup for syncope

A

Cardiac - Start with this
Neuro - Consider after
Ask to describe dizziness for vertigo vs. lightheadedness

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77
Q

Seizure vs. True Syncope

A

Seizure has a post-ictal phase, true syncope does not

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78
Q

Presentation of vasovagal syncope

A

Fainting after seeing blood, etc., w/ prodrome (pallor, nausea, warmth, diaphoresis, blurred vision)
60% of patients with a heart condition

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79
Q

Presentation of cardiac syncope

A

No prodrome and w/ exercise
Syncope while supine

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80
Q

Presentation of reflex syncope

A

After exercise with a drop in HR and BP

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81
Q

Presentation of psychogenic syncope

A

Long lasting, no post ictal phase - suspect

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82
Q

3 potential associated signs of syncope

A

HA - SAH
Chest Pain - MI, PE
Fever - Sepsis

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83
Q

QT and syncope

A

Check for meds - Zophran, Psych, Macrolides, FQ, Antipsychotics, Diuretics, nDHP-CCB
May have gone into torsades
EKG of 450+ is concerning

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84
Q

Physical exam for syncope

A

Head and Neck Trauma
Skin Turgor
Abdomen for AAA
Rectal exam for bleed

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85
Q

Who gets a CT for syncope

A

Neuro deficit
Trauma to head - Canadian CT rules

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86
Q

How long should syncope last

A

Less than a minute

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87
Q

Orthostatic syncope presentation

A

Change in position causes BP to drop causing a reflexive tachycardic response

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88
Q

Carotid sinus syncope

A

Tight collar, Head turn, Shaving - leading to push on artery
Hx of atherosclerosis
Use carotid massage to dx
Midodrine

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89
Q

Positive dx for carotid sinus syncope

A

Decrease of SBP by 50+ upon carotid sinus massage

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90
Q

ED care for aortic stenosis

A

Avoid: Nitro, BB, CCB
Admit for TAVR

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91
Q

Murmur of aortic stenosis

A

Systolic ejection crescendo-decrescendo at the right upper sternal border
1st post with radiation to the neck
Split S2

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92
Q

Presentation of Aortic stenosis

A

Murmur is worse with squatting and expiration
Murmur decreases with valsalva
Syncope and LVH

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93
Q

Murmur of Aortic regurg

A

Early diastolic, soft-blowing decrescendo murmur with a high-pitch quality, especially when the patient is sitting and leaning forward heard at the left lower sternal border

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94
Q

Presentation of aortic regurg

A

Increases with squatting, decreases with valsalva
History of congenital heart defect or rheumatic fever

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95
Q

Murmur of mitral stenosis

A

Rumbling diastolic murmur with a split s1 that occurs following an opening snap. The rumbling is loudest at the start of diastole and is heard best at the left sternal border and apex

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96
Q

Presentation of mitral stenosis

A

Opening snap and murmur at LLSB/Apex
Left atrial hypertrophy - golden arches P wave on EKG lead II
SOB and CHF from fluid backup
Increase with squatting, decreases with valsalva

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97
Q

Murmur of mitral regurg

A

Blowing HOLOSYSTOLIC murmur at APEX with a SPLIT S2, radiates to the axilla

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98
Q

Presentation of mitral regurg

A

Previous STEMI
Low BP with tachycardia
Lung crackles

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99
Q

Presentation of AAA

A

Pulsatile abdominal mass
Flank pain
Hypotension

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100
Q

Management of AAA

A

Surgical repair if > 5.5 cm or expands > 0.6 cm per year
Monitor annually if > 3 cm.
Monitor every 6 months if > 4 cm
Beta-blockers

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101
Q

Presentation and Diagnostics for Aortic Dissection

A

Tearing chest pain radiating to the back
Widened mediastinum on CXR

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102
Q

Management for ascending and descending aortic dissections

A

Ascending aorta- Surgical emergency
Descending aorta- Medical therapy (beta-blockers) unless complications are present

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103
Q

6 P’s of arterial occlusion

A

Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia

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104
Q

2 MCC of thrombus formation

A

A-fib
Mitral Stenosis

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105
Q

Diagnosis and management for arterial occlusion

A

Angiography is gold standard
Treat with IV heparin if not limb-threatening then call the vascular surgeon for angioplasty, graft, or endarterectomy

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106
Q

Presentation of thrombophlebitis

A

Spontaneous or following IV/PICC line trauma
Pain, erythema, induration, palpable cord

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107
Q

Diagnosis and management of thrombophlebitis

A

Duplex ultrasound Gold Standard for diagnosis
Treatment: Symptomatic: NSAIDs, warm compress

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108
Q

Presentation of cervical sprain

A

Stiffness/pain in the neck; presents with paraspinal muscle tenderness and spasm and + Spurling test

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109
Q

Spurling test

A

Passive cervical extension, Ipsilateral rotation, and Axial compression with pain down the ipsilateral side

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110
Q

Management of a cervical sprain

A

Soft cervical collar (2-3 days), application of ice /heat, analgesics, gentle active ROM soon after injury

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111
Q

Presentation of thoracic or lumbar back strain

A

Axial back pain with difficulty bending
No radicular symptoms - pain below the knees

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112
Q

Management for a thoracic/lumbar back strain

A

Bed rest < 2 days + NSAIDs ± muscle relaxants if no red flag symptoms

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113
Q

6 red flag symptoms of back pain

A

You’ve Been in Pain for Over a Week
Your Pain Extends to Other Body Parts
You Have Numbness, Tingling or Weakness
You Have Pain After an Accident
Your Pain is Worse at Certain Times or in Certain Positions
You’re Having Problems with Your Bowels or Urination

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114
Q

Strain

A

Involves muscles/ligaments

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115
Q

Sprain

A

Involves tendons

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116
Q

Olecranon bursitis

A

Scholar’s elbow
Pain or fever may suggest septic bursitis
Gout also possible etiology

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117
Q

Management of olecranon bursitis

A

NSAIDs, Rest, Abx, steroid injection, surgery

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118
Q

Prepatellar bursitis

A

Housemaid’s knee
Pain with direct knee pressure (ie. kneeling)
Often septic in wrestlers

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119
Q

Management of prepatellar bursitis

A

Compression, NSAID, aspiration, immobilization

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120
Q

Presentation of subacromial bursitis

A

Often not associated with trauma
Pain with motion and rest
Similar to rotator cuff impingement

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121
Q

3 indications to aspirate subacromial bursitis

A

Fever
Diabetes
Immune compromise

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122
Q

Presentation of patellar tendonitis

A

Anterior knee pain
Basset’s sign - tenderness to palpation at the distal pole of the patella in full extension and no tenderness to palpation at the distal pole of the patella in full flexion

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123
Q

Management of patellar tendonitis

A

Ice, Rest, NSAID
Steroids - CONTRAINDICATED tendon rupture

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124
Q

Presentation of biceps tendonitis

A

Pain in the bicipital groove
Anterior shoulder pain and pain with resisted supination of the elbow
Popeye deformity = rupture

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125
Q

Management of biceps tendonitis

A

NSAID, PT, Steroids, surgery if refractory

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126
Q

2 special tests for biceps tendonitis

A

Speed test: Pain elicited in the bicipital groove when the patient attempts to forward elevate shoulder against examiner resistance while the elbow extended, and forearm supinated. Positive if the pain is reproduced. May also be positive in patients with SLAP lesions.

Yergason’s test: Elbow flexed 90 degrees, wrist supination against resistance. Positive if the pain is reproduced.

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127
Q

Presentation of cauda equina

A

Large midline disk herniation compressing several nerves
Saddle anesthesia, incontinence, paralysis

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128
Q

Diagnosis and management of cauda equina

A

MRI
SUrgical emergency

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129
Q

Presentation of costochondritis

A

Pain and tenderness on the breastbone, pain in more than one rib, or pain that gets worse with deep breaths or coughing
MC unilateral with pain on movement
Reproducible with palpation

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130
Q

Diagnosis for costochondritis

A

CRX, Biopsy, EKG, VItamin D to rule out other causes

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131
Q

Management of costochondritis

A

NSAIDS, Heat, Compression, potentially PT or steroids

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132
Q

Tietze syndrome

A

Inflammatory process causing visible enlargement of the costochondral area “slipping rib syndrome”

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133
Q

Management and pearls for eccymosis

A

Ice and NSAIDs
Bruising on an extremity is a fracture until proven otherwise

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134
Q

Pearls for erythema

A

Erythema is smoke not fire (needs to find underlying cause)
Often indicates that infection needs to be rules out

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135
Q

Humeral Fracture
Nerve commonly injured?
SIgn?
Splint type?
Follow up?

A

MC site of radial nerve injury; posterior fat pad/sail sign, treat with sugar tong splint (distal) and coaptation splint (shaft) with ortho follow up in 24-48 hours

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136
Q

Supracondylar Fracture (Humerus right above the condyles)
Common demographic?
Mechanism?
XR Findings?
Nerve and Artery commonly involved?
Splinting?

A

MC pediatric elbow fracture; usually from fall to outstretched hand; XR shows anterior fat pad (dark area on either side of the bone), check neurologic/vascular involvement (median nerve / brachial artery injury), long arm posterior splint followed by long arm casting (ORIF for displaced)

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137
Q

Nursemaid’s Elbow (Rad Head Subluxation)
Presentation?
Mechanism?
Management technique?

A

Lateral elbow pain, hold the elbow in slight flexion and forearm pronated; pain and tenderness localized to the lateral aspect of the elbow; usually from pulling upward motion; the supination-flexion technique is classically used

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138
Q

Radial Head Fracture
Presentation?
MCC?
Management and splinting?

A

Pain and tenderness along the lateral aspect of the elbow, limited elbow/forearm ROM, particularly pronation/supination; MC cause is falling on an outstretched arm; treat with a sling, long arm splint at 90 degrees, ORIF

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139
Q

Nightstick Fracture of the Ulna
MCC?
Management for displaced vs. Non displaced?

A

Usually from a blow; functional brace with good interosseous mold for isolated nondisplaced or distal 2/3 ulna shaft fx; ORIF if displaced

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140
Q

Monteggia Fracture
Definition?
Presentation?
Mechanism?
Potential Nerve Injury?
Management?

A

Proximal ulnar shaft fracture with radial head dislocation. elbow pain and swelling, tenderness to palpation along the elbow, decreased elbow ROM, the radial head may be palpable if dislocated. FOOSH, radial nerve injury, treat with ORIF

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141
Q

Galeazzi Fracture
Definition?
Presentation?
MCC?
Management?

A

Distal radial shaft fracture, dislocation of ulna. Wrist pain, swelling, pain with flexion/extension; FOOSH, falling on pronated hand, unstable fracture = ORIF, long arm splint

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142
Q

Colles Fracture
Definition?
Mechanism?
Deformity?
XR view for diagnosis?
Management?

A

Dorsally angulated extra-articular distal radius fracture; “fragility fracture”; FOOSH; causes dinner fork deformity; need lateral XR to make the diagnosis; treat with sugar tong splint/cast

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143
Q

Smith Fracture
Definition?
MCC?
Deformity?
Nerve injury?
Management?

A

Extra-articular metaphysis fracture of the radius with volar angulation and displacement – garden spade deformity; from fall with palm closed, hands flexed, blow to the back of wrist; median nerve injury = common (can develop carpal tunnel over time); reduction/surgery or casting, PT for ROM and strengthening

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144
Q

Management of a snuffbox fracture

A

Thumb spica splint for 10-12 weeks

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145
Q

Boxer’s Fracture
Definition?
MCC?
Splinting type and degree?

A

Fracture of neck of 5th/4th metacarpal; usually from s punch with a clenched fist; treat with ulnar gutter splint with joints at 60-degree flexions

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146
Q

Shoulder Fracture
Demographic?
Complication?
Workup?
Management?

A

Common in elderly, complication = adhesive capsulitis/rotator cuff tear; MRI to r/o rotator cuff tear; scapular fractures often missed after MVA; tx = immobilize 2-3 weeks the begin with gentle passive ROM and modalities; progress to light strengthening after 6 weeks

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147
Q

SHoulder Dislocation MOA

A

Arm is abducted and externally rotated (FOOSH)

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148
Q

Shoulder dislocation presentation, anterior, posterior

A

Anterior: MC (arm = anterior) ⇒ arm is abducted and externally rotated (FOOSH)
Posterior: the arm is adducted and internally rotated

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149
Q

Imaging and management of shoulder dislocation

A

AP, axillary, and scapular view
Reduce, post-reduction films, sling, and swath, PT

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150
Q

Common nerve injury in shoulder dislocation

A

Axillary nerve

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151
Q

Bankart lesion

A

Injury of the anterior (inferior) glenoid labrum following a dislocated shoulder

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152
Q

Hill-Sachs Lesion

A

Dent in the humeral head due to dislocation
Compression chondral injury of the posterior superior humeral head following impaction against the glenoid

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153
Q

Clavicular Fracture
Location MC?
Presentation?
Assoc. MC RC injury?
XR’s to order?
Management?

A

Usually middle third of clavicle
Swelling, erythema, tenderness to palpation, tenting of overlying skin,
MC injured rotator cuff muscle = supraspinatus
X-ray: anteroposterior and clavicle view
Tx: simple arm sling or figure of eight sling: 4-6 weeks adults, ortho consult if proximal 1/3; begin PT after 4 weeks with light strengthening after 6 weeks

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154
Q

Presentation of a hip fracture

A

Severe hip or groin pain after a fall
Positive Log Roll maneuver
Pain with active and passive ROM

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155
Q

Main blood supply to femoral neck

A

Medial circumflex femoral artery

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156
Q

Imaging for a hip fracture

A

AP X-ray of the pelvis
Look for Avascular necrosis

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157
Q

Management of hip fracture

A

Manage with ORIF; hip arthroplasty, DVT prophylaxis until ambulatory

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158
Q

More common hip dislocation

A

Posterior

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159
Q

Presentation of posterior hip dislocation

A

adducted, flexed, internally rotated

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160
Q

Presentation of anterior hip dislocation

A

abducted, flexed, externally rotated

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161
Q

One thing to r/o and one thing to prevent in hip dislocation

A

Sciatic nerve injury
DVT - prevent

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162
Q

X ray results for hip dislocation, anterior v. posterior dislocation

A

Anterior - Femoral head below acetabulum
Posterior - Femoral head above acetabulum

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163
Q

Management of hip dislocation

A

Closed reduction, open if failure
XR and neurovascular check after reduction

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164
Q

Ottowa Knee Rules - 5

A

SENSITIVE (rule out)
Age > 55
Tenderness to the head of the fibula
Isolated tenderness to the patella
Inability to flex the knee to 90 degrees
Inability to bear weight for 4 steps both immediately and in examination room regardless of limp

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165
Q

Pittsburgh Knee Rules - 3

A

SPECIFIC - Rule in
Recent fall or blunt trauma
Age < 12 y/o or > 50 y/o
Unable to take 4 unaided steps

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166
Q

Knee dislocation

A

Usually after high impact trauma
Concern for popliteal artery injury
CT angiogram to dx
Pre and post XR and MRI

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167
Q

Tibial Plateau Fracture

A

Usually peds in MVA
Lateral oblique XR
Peroneal nerve check (foot drop)
Nondisplaced - 6-8 weeks cast
Displaced - ORIF

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168
Q

Patellar Fracture

A

Patella Alta (pulled quad muscles cause fracture displacement; tx = 6-8 weeks immobilization, may bear partial eight; displaced need ORIF

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169
Q

Knee osteoarthritis

A

Space narrowing and osteophytes
Weight reduction, moderate activity, NSAIDs, intra-articular steroid injection, bracing, canes, muscle strengthening, PT;
acetaminophen = first line,
NSAIDs = second line;
total joint replacement indicated in advanced cases

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170
Q

Ottowa Ankle Rules (3)

A

Pain along lateral malleolus, medial malleolus
Midfoot pain, 5’th metatarsal or navicular pain
Unable to walk more than four steps in the ER or exam room

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171
Q

Jones Fracture

A

5th metatarsal diaphysis fracture
Lateral foot pain
Due to poor blood supply
AP, Lat, Oblique XR
NWB for 6 weeks
RICE +boot

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172
Q

Most common foot stress fracture

A

3rd metatarsal - athlete, military
May not show up on XR, may need MRI

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173
Q

Talus fracture

A

High force impact (falling/snowboarding), X-ray demonstrates talus fracture, non-weight bearing cast for non-displaced, surgery for displaced

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174
Q

Class A Weber ankle fracture

A

INVERT
Fibular fracture below mortise, tibiofibular syndesmosis intact, usually unstable

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175
Q

Class B Weber ankle fracture

A

EVERT
Fibular fx at the level of the mortise, tibiofibular syndesmosis intact or mild tear, deltoid ligament intact or may be torn, stable or unstable

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176
Q

Class C Weber ankle fracture

A

LATERAL PUSH
Fibular fx above Mortise, tibiofibular syndesmosis torn with a widening of talofibular joint, deltoid ligament damage or medial malleolar fracture, unstable = ORIF

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177
Q

Presentation of true gout

A

Men over 30 (more common in women poste menopause)
Assymmetric tophi - great toe
Pain, swelling redness, tenderness

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178
Q

Podagra

A

Sudden gout attack

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179
Q

Labs/Diagnostics of gout

A

Rod shaped negatively birefringent crystals
Serume uric acid over 8
Punched out lesions on XR

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180
Q

Lifestyle modifications for gout

A

Elevation, rest, decrease purines (meats, beer, seafood, alcohol), weight loss, increase protein, limit alcohol

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181
Q

Management of gout attack

A

Indomethacin is best
Colcicine (bad GI s/e) or steroids if not tolerated

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182
Q

Meds to avoid in gout

A

Thiazide diuretics
Aspirin
No allopurinol while acute

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183
Q

2 drugs for long term gout management

A

Allopurinol
Colchicine

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184
Q

Presentation of pseudogout

A

Over 60, Large joint involvement without LE tophi
Rhomboid, birefringent, calcium pyrophosphate crystals
Linear calcifications of XR

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185
Q

Management of pseudogout

A

NSAIDs, colchicine, intra-articular steroid injections
Colchicine = prophylaxis, NSAIDs = acute attacks

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186
Q

C4 herniated disk presentation

A

May affect the levator scapular and trapezius muscles, resulting in weakness in shoulder elevation. There is no reliable associated reflex.

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187
Q

C5 herniated disk presentation

A

Weakness of the rhomboid, deltoid, bicep, and infraspinatus muscles. Patients may have weakness of shoulder abduction and external rotation.
The bicep reflex may be diminished.

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188
Q

C6-7 herniated disk presentation

A

Produces pain at the shoulder tip and trapezius with radiation to the anterior upper arm, radial forearm, and thumb, and sensory impairment in these areas.
Weakness can overlap with the C5 or C7 muscles.
Muscles affected include infraspinatus, bicep, brachioradialis, pronator teres, and triceps. Weakness involves flexion at the elbow, or shoulder external rotation.
The bicep or brachioradialis reflex may be diminished.

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189
Q

C7-T1 herniation presentation

A

Weakness can be present in the opponens pollicis, flexor digitorum profundus, flexor pollicis longus, and hand intrinsic muscles.
Clinically, patients present with symptoms similar to an ulnar or median motor neuropathy and can have weakness of finger abductors and grip strength; they may also have findings suggesting median motor neuropathy.
No reliable reflex test is available.

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190
Q

Sciatica

A

Back pain radiating through thigh/buttocks (lower leg below the knee down L5-S1) –
Do straight leg raise, crossover test; dx = non-contrast MRI;
Tx: NSAIDs, rest, steroids, PT, epidural steroid injection, surgery if warranted

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191
Q

L! Herniation

A

Rare, causes inguinal pain

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192
Q

L2-L4 hernitation and issues

A

Older patients with spinal stenosis
Anterior aspect of thigh and knee affected

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193
Q

L5 herniation presentation

A

Most common herniation
Posterior aspect of the leg into the foot from the back. On examination, strength may be reduced in leg extension (gluteus maximus) and plantar flexion. Sensation is generally reduced on the posterior aspect of the leg and the lateral foot. Ankle reflex loss is typical.

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194
Q

S3-4 herniation management

A

Patients can present with sacral or buttock pain that radiates down the posterior aspect of the leg or into the perineum. Weakness may be minimal, with urinary and fecal incontinence as well as sexual dysfunction.

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195
Q

MCC of lower back pain - 2 and time to present

A

Prolapsed intervertebral disk and low back strain. Usually occurs within 24 hours of injury/overuse

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196
Q

Presentation of back pain

A

Sciatica/Pain radiating down a leg
MSK injury creates localized point tenderness
SI joint involvement gets worse with standing
Spinal Stenosis improves with leaning forward

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197
Q

Diagnostics for lower back pain

A

CT, MRI, XR if persistent
Leg lift test

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198
Q

Management of back pain

A

Short term rest (max 2 days), with support under knees and neck + NSAIDs
Imaging if lasting over 6 weeks
PT

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199
Q

Presentation of osteomyelitis

A

Fever, restriction of movement and non-weight bearing
May be due to contiguous spread or due to trauma/surgery

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200
Q

Organisms od osteomyelitis
MC
Cat/dog bite
Sickle cell
Vertebra
Prosthetic

A

MC - S. Aureus
CAT/Dog - Pasturella
Sickle cell - salmonella
Vertebrae - TB\Prosthtic - S. epidermitis

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201
Q

Diagnosis for osteomyelitis

A

Bone aspiration - GOLD STANDARD
Demineralization, periosteal reaction, bone destruction (MRI showes before XR)
Elevated ESR/CRP
Blood culture

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202
Q

Management of osteomyelitis

A

Remove ALL hardware
IV ABX 4-6 weeks acute; 8+ weeks chronic

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203
Q

Diabetic ulcer likely for osteomyelitis

A

Over 2cmx2cm foot ulcer

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204
Q

Management of acute v chronic pain

A

Acute - determine if nociceptive or neuropathic
Chronic - Consult with regular provider

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205
Q

NSAID Ceiling effect for Naproxen, Diclofenac, and Ibuprofen

A

Naproxen: 500 mg (1000 mg/day)
Ibuprofen: 400 mg (1200 mg/day)
Diclofenac: 50 mg (150 mg/day)

206
Q

NSAIDS in CKD

A

Not absolutely CI
Weight risk/benefit

207
Q

4 Risk Factors for NSAID GI toxicity

A

History of a previously complicated ulcer
Age >65
High dose NSAID therapy
Concurrent use of aspirin/corticosteroids/anticoagulants

Use PPI

208
Q

5 special pain management cases and tx

A

Consider topical analgesic patches (lidocaine 5%)
Consider Cymbalta for a combination of pain and depression
Consider COX 2 inhibitors such as Celebrex or Mobic
Consider muscle relaxants such as baclofen, cyclobenzaprine (Flexeril), tizanidine (Zanaflex), etc.
Consider gabapentin or TCAs (nortriptyline) for neuropathic pain

209
Q

4 pearls of opioid use

A

Discuss goals of tx
Short, low dose course
Combine with NSAID or TYlenol
Oral preferred over IV

210
Q

Presentation of septic arthritis

A

Single swollen warm and painful joint with fever and systemic symptoms
Knee and hip are MC places

211
Q

3 common pathogens for septic arthritis

A

Staph Aureus in normal
Gonorrhea more common if sexually active
Pseudomonas in IVDU

212
Q

Diagnosis of septic arthritis

A

50,000+ WBCs in joint aspirate
Or 1,000+ in prostetic joints

213
Q

Management of septic arthritis (3 regimens for 3 microbes)

A

Treatment is based on gram stain- 2–4-week course of antibiotics + arthrotomy with joint drainage

Staph aureus = Vanco/nafcillin (Vanco or Clindamycin if PCN allergic)
Gonorrhea = ceftriaxone
IVDU = Cipro/Levaquin

214
Q

Medial epicondylitis

A

Golfer/Pitcher elbow
pain with resisted wrist flexion and pronation, pain at the medial elbow may radiate to the wrist; tx: activity modification, PT, steroid injection, surgery for a patient who failed PT for 4-6 mo

215
Q

Lateral epicondylitis

A

Tennis elbow
Pain with wrist extension and forearm supination; tx: activity modification, counterforce bracing, PT, steroid injection, surgery for failed PT 4-6mo

216
Q

Signs for carpal/ulnar tunnel syndromes

A

Phalen (only CT) and Tinnell (both)

217
Q

Management of ulnar/carpel tunnel syndrome

A

NSAIDs
Splinting
Steroid injection
Decompression if severe

218
Q

De Quervain’s Tenosynovitis

A

Positive finklestein test (thumb in fist)
Swelling in thumb radiates to radial forearm
Thumb spica splint x 3 weeks,
NSAIDs 10-14 days,
steroid injections, PT

219
Q

2 Thumb collateral ligament injuries

A

Ulnar collateral ligament injury from fall on an abducted thumb
Gamekeeper = chronic; skier = acute
Laxity and pain with valgus stretch; XR to evaluate for avulsion injury
Tx: thumb spica splint 4-6 weeks

220
Q

Dupuytren Contracture presentation

A

MC in digits 4&5
Contracture of palms and palmar nodules – associated with alcoholic cirrhosis – painless nodules on palms, may limit function; tabletop test positive (lie flat on the tabletop)

221
Q

Diagnosis and management of Dupuytren Contracture

A

Dx - Clinical;
Tx: injected collagenase or steroid, fasciotomy or fasciectomy if pt is refractory to 1st line therapy

222
Q

Mallet Finger

A

(baseball – tear at DIP joint): avulsion of extensor tendon ⇒ forced flexion; can’t straighten distal finger

223
Q

Management of mellet finger

A

XR = bony avulsion of the distal phalanx; tx: splint DIP uninterrupted extension x6 weeks or surgical pinning

224
Q

Boutonniere deformity

A

Tear at PIP joint – jammed finger): PIP flexion and DIP hyperextension, usually from jammed finger; Elson test = bend PIP 90 degrees over the edge of the table and extend middle phalanx against resistance ⇒ weak PIP extension and DIP will be rigid

225
Q

Management of Boutonniere deformity

A

XR not required; tx: splint PIP in extension x4-6 weeks

226
Q

Felon

A

Infection of the pulp space of the fingertip, usually with staphylococci and streptococci

227
Q

Herpetic whitlow:

A

Herpes virus infection around the fingernail (thumb sucking)

228
Q

Management of ganglion cyst

A

Allen’s test to ensure radial and ulnar artery flow; U/S can differentiate a cyst from a vascular aneurysm; most ganglia don’t require treatment - observe. Aspirate (avoid on the volar aspect of wrist d/t radial artery – effective on only 50% of pt. Excision (severe sx or neurovascular manifestations)

229
Q

AC joint separation

A

From FOOSH or direct shoulder trauma
Step up deformity and pain with cross chest testing

230
Q

Eval and management for AC joint separation

A

XR with patient holding weight to assess severity
Sling and analgesia, surgery if more severe

231
Q

Biceps tendonitis

A

Popey deformity
Pain at bicipital groove
NSAIDs, PT, steroid injection; surgical release for refractory cases

232
Q

2 signs for biceps tendonitis

A

Speed’s: patient attempts to forward elevate shoulder against examiner resistance while the elbow extended and forearm supinated; positive with pain (SLAP lesion)
Yergason’s elbow flexed at 90, wrist supination against resistance

233
Q

Imaging and Management for rotator cuff tear/ tendonopathy

A

XR = initial imaging (loss of subacromial space due to upward migration of humeral head), MRI = most accurate;
Tx = NSAIDs, steroid injection and surgical repair if you fail 3-6mo of conservative

234
Q

Rotator cuff muscles with tests (3)

A

Supraspinatus: empty can test, full can test, arm drop
Subscapularis: lift-off test (elbow at 90, rotate medially against resistance)
Teres minor/infraspinatus: elbow at 90, rotate laterally against resistance

235
Q

Special test and management for adhesive capsulitis

A

Apley scratch test; tx = NSAIDs, PT, steroid injection

236
Q

3 tests for subacromial impingement

A

Neer test: arm fully protonated with pain during forward flexion while shoulder is being held
Hawkins: elbow/shoulder flexed at 90 with sharp anterior shoulder pain with internal rotation
Drop arm: pain with inability to lift the arm above shoulder or hold it

237
Q

Management for subacromial impingement

A

XR may show a subacromial spur
Tx: rest, ice, activity modification, NSAIDs, steroid injection, arthroscopic surgery if refractory to conservative

238
Q

Patellar tendonitis-Presentation

A

Activity-related, “jumper’s knee”, swelling over tendon and tenderness at the inferior border of the patella

239
Q

Diagnosis of patellar tendonitis

A

XR may show inferior traction spur in chronic cases (enthesophyte), U/S = thickening tendon and hypoechoic areas; MRI shows tendon thickening;

240
Q

Management of patellar tendonitis

A

Ice, rest, activity modification, PT; surgical excision and suture repair as needed;
Steroid injection = CI d/t risk of tendon rupture!!!!!

241
Q

Presentation and management of ACL tear

A

Pop with knee giving out
Positive lachman’s test (most sensative)
MRI to confirm with PT and surgery for young active patients

242
Q

MCL and LCL injury presentation and management

A

MCL: valgus stress injury (hit in football); “pop” along with medial joint line pain, MRI = definitive; conservative tx with bracing and therapy = effective; surgery for chronic instability; Valgus stress test
LCL: trauma to the inside of the knee; rare; MRI = definitive study; conservative treatment with bracing and therapy usually effective; surgery for grade III injury; Varus stress test

243
Q

Mechanism and presentation of PCL tear

A

Blow to the knee while flexed or bend like landing hard during sports fall
Posterior drawer sign or sag sign

244
Q

Management for PCL tear

A

MRI = confirms; protected weight-bearing and rehab for isolated grade I and II; surgical repair for PCL + ACL or PCL and PCL + grade III MCL or LCL

245
Q

Meniscal Tear

A

After twisting injury with locking, feeling of the knee giving away, a triad of joint line pain, effusion, locking; effusion usually 6-24 hours after injury; McMurray test/Apley test

246
Q

3 lateral ligaments of the ankle

A

anterior talofibular ligament (ATFL) - MC injury
calcaneofibular ligament (CFL), and
posterior talofibular ligament (PTFL)

247
Q

Test for achilles tendon rupture

A

THompson test (calf squeeze)

248
Q

Management of achilles tendon rupture

A

Surgical repair for early ROM, splint with the ankle in some plantar flexion

249
Q

Plantar fasciitis
Presentation
Management
Tx

A

Pain on the plantar surface, usually at calcaneal insertion of plantar fascia upon weight bearing especially in the morning/initiation of walking after prolonged rest (dancers, runners); tx: stretching, ice, calf strengthening, shoe inserts, NSAIDs

250
Q

Tarsel Tunnel
Presentation
Sign
Dx
Tx

A

Posterior tibial nerve compression from overuse, restrictive footwear, + Tinel’s sign, dx: nerve conduction test/electromyography; tx: avoid exacerbating activities, NSAIDs, steroid injection if no improvement, surgery

251
Q

Bunion/Hallux Valgus
Presentation
Dx
Management

A

Deformity of the bursa over 1st metatarsal; hx of poorly fitted shoes / flat feet (pes planus); or RA; pain over prominence at MTP joint / pain with shoes,
dx = XR,
tx = comfortable wide toed shoes; surgical when sx present despite shoe modification

252
Q

Morton neuroma
Sx
Dx
Tx

A

Painful mass near tarsal heads; MC in women with tight-fitting shoes, high heels; sharp pain with ambulation at 3rd metatarsal head; associated with numbness/paresthesia; MRI may be needed for diagnosis; tx = wide shoes, steroid injections, surgical resection if conservative management fails

253
Q

3 degrees of sprains

A

1 - Stretched but intact
2 - 1/3 to complete tear
3 - Complete rupture with avulsion potentially

254
Q

Ice application for sprains and strains

A

10–15 minutes at a time, 3-4 times a day.

255
Q

2 MC strain locations

A

Hamstring muscle and the lower back

256
Q

3 degrees of strains

A

First degree (mildest) – little tissue tearing; mild tenderness; pain with a full range of motion.
Second degree – torn muscle or tendon tissues; painful, limited motion; possibly some swelling or depression at the spot of the injury.
Third-degree (most severe) – limited or no movement; severe acute pain, though sometimes painless straight after the initial injury

257
Q

5 Hepatic Causes of RUQ pain

A

Acute hepatitis RUQ pain with fatigue, malaise, nausea, vomiting, and anorexia. Patients may also have jaundice, dark urine, and light-colored stools

Perihepatitis (Fitz-Hugh-Curtis syndrome) RUQ pain with a pleuritic component, pain is sometimes referred to the right shoulder

Liver abscess Fever and abdominal pain are the most common symptoms

Budd-Chiari syndrome Symptoms include fever, abdominal pain, abdominal distention (from ascites), lower extremity edema, jaundice, gastrointestinal bleeding, and/or hepatic encephalopathy

Portal vein thrombosis Symptoms include abdominal pain, dyspepsia, or gastrointestinal bleeding

258
Q

4 splenic causes of LUQ pain

A

Splenomegaly Pain or discomfort in LUQ, left shoulder pain, and/or early satiety

Splenic infarct Severe LUQ pain

Splenic abscess Associated with fever and LUQ tenderness

Splenic rupture May complain of LUQ, left chest wall, or left shoulder pain that is worse with inspiration

259
Q

Presenation and MC etiology of appendicitis

A

MCC - Fecalith
The first symptom is crampy or “colicky” pain around the navel (periumbilical) → then pain over McBurney’s point (RLQ)
N/V and anorexia

260
Q

3 signs of appendicitis

A

Rovsing – RLQ pain with palpation of LLQ
Obturator sign – RLQ pain with internal rotation of the hip
Psoas sign - RLQ pain with hip extension while laying on the left side

261
Q

Dx and Tx of appendicits

A

Imaging if atypical presentation - appy ultrasound or abdominal CT scan
CBC - neutrophilia supports the diagnosis
TX: surgical appendectomy

262
Q

Definitions of cholelithiasis, cholangitis, cholecystitis, and choledocholithiasis?

A

Cholelithiasis: Gallstones within the gallbladder sac
Cholangitis: Inflammation of the common bile duct, often caused by infection or choledocholithiasis
Cholecystitis: Inflammation of the gallbladder
Choledocholithiasis: Gallstones that have migrated from the gallbladder sac into the common bile duct.

263
Q

Presentation of cholelithiasis

A

Stones in the gallbladder, Asymptomatic (most), symptoms only last few hours
Biliary colic—RUQ pain or epigastric
Pain after eating and at night
Boas sign—referred right subscapular pain

264
Q

Dx and Tx for cholelithiasis

A

RUQ ultrasound - high sensitivity and specificity if >2 mm. CT scan and MRI
TX: Asymptomatic—no treatment necessary

Elective cholecystectomy for recurrent bouts

265
Q

Presentation of cholecystitis

A

Gallstones with inflammation
5 Fs: Female, Fat, Forty, Fertile, Fair
(+) Murphy’s sign (RUQ pain with GB palpation on inspiration)
RUQ pain after a high-fat meal
Low-grade fever, leukocytosis, jaundice

266
Q

Dx and management of cholecystitis

A

Ultrasound is the preferred initial imaging - gallbladder wall >3 mm, pericholecystic fluid, gallstones
HIDA is the best test (Gold Standard) - when ultrasound is inconclusive
CT scan - alternative, more sensitive for perforation, abscess, pancreatitis
Labs: ↑ Alk-P and ↑ GGT, ↑ conjugated bilirubin
Porcelain gallbladder = chronic cholecystitis

Cholecystectomy to treat

267
Q

Dx for choledocholithiasis

A

ERCP = gold standard

268
Q

Presentation of acute hepatitis

A

Recent travel with sudden jaundice, RUQ pain, scleral icterus, fever
HAV, Parasites, Alcohol can cause it

269
Q

Diagnosis of acute hepatitis

A

Hepatomegaly and GB thickening on US
Hyperbilirubinemia with elevated AST and ALT

270
Q

Liver enzyme suggestive of alcoholic hepatitis

A

AST:ALT>2

271
Q

Anti-HBcIgM and HBsAG present

A

Acute HBV

272
Q

HBSAg alone

A

Early HBV disease

273
Q

Anti-HBcIgG and Anti-HBs

A

Resolve acute hepatitis

274
Q

AntiHBs only

A

Vaccinated and resistant

275
Q

AntiHBcIgG and HBsAg

A

Chronic HBV

276
Q

Supportive care for Hepatitis

A

Fluids
Manage clotting issues
Manage encephalopathy
THiamine/Folate supplementation

277
Q

Medical therapy for hepatitis

A

Entacavir for severe HBV
Pentoxifylline or steroids for severe alcoholic hepatitis

278
Q

Diagnostics for pancreatitis

A

Abdominal CT is the diagnostic test of choice - required to differentiate from necrotic pancreatitis
ERCP is the most sensitive for chronic pancreatitis

279
Q

GET SMASHHED causes of pancreatitis

A

Gallstones, Ethanol, Trauma, Steroids, Mumps, Autoimmune disease, Scorpion sting, Hypercalcemia, Hyperlipidemia, ERCP and Drugs.

280
Q

Pancreatitis 5 Ransons criteria for poor prognosis at admission

A

Age > 55
Leukocyte: >16,000
Glucose: >200
LDH: >350
AST: >250

281
Q

6 Ransons criteria at 48 hours

A

Arterial PO2: <60
HCO3: <20
Calcium: <8.0
BUN: Increase by 1.8+
Hematocrit: decrease by >10%
Fluid sequestration >6L

282
Q

Presentation and management of anorectal abcess, or fistula

A

Painful defectation with swelling and fluctuance at the anus. Fever is not common
Treat with drainage and surgery if needed. Abx in at-risk patients

283
Q

Presentation and management of anal fissure

A

Tearing rectal pain with bright red bleeding after
Superficial cut
Sitz bath - heals in 6 weeks
Botox if failing conservative tx

284
Q

4 signs of appendicitis

A
  1. Periumbilical pain (intermittent and crampy) 2. Nausea/vomiting 3. Anorexia 4. Pain migrates to RLQ (constant and intense pain), usually in 24 hours
285
Q

MC disease presenting with anorexia

A

Appendicitis

286
Q

WEAPON mneumonic for gastric cancer

A

Weight loss, Emesis, Anorexia, Pain/epigastric discomfort, Obstruction, Nausea

287
Q

6 Medications causing anorexia

A

sedatives, digoxin, laxatives, thiazide diuretics, narcotics, antibiotics

288
Q

5 differentials to consider in constipation

A

Colorectal cancer (always consider if over 50)
Bowel obstruction - Air fluid levels and dilated loops on XR
Volvulus - XR with colonic distension
Ileus - Absent bowel sounds
Gastroparesis - (diabetes) vomiting, abdominal pain, fullness after eating small amounts

289
Q

Presetation of cholangitis with pentad and triad

A

Infection of billiary tract
Charcot’s triad - Pain, Fever, Jaundice
Reynauds pentad - Charcot + Altered mental status and hypotension

290
Q

DIagnosis for cholangitis

A

US - Initial
ERCP - Best

291
Q

Management of cholangitis

A

Cipro and Flagyl
ERCP to remove stones
Cholecystectomy post-acute

292
Q

Primary sclerosing cholangitis

A

Jaundice and pruritus
Associated with IBD, cholangiocarcinoma, pancreatic cancer, colorectal cancer

293
Q

Budd-CHiari syndrome

A

Hepatic vein thrombosis
Triad of abdominal pain, ascites, and hepatomegaly

294
Q

Presentation of hepatic encephalopathy

A

Ammonia accumulates and reaches the brain causing ↓ mental function, confusion, poor concentration
Asterixis (flapping tremor) - have patient flex hands
Dysarthria, delirium, and coma

295
Q

Presentation of esophageal vein rupture

A

Dilated submucosal veins, retching or dyspepsia, hypovolemia, hypotension, and tachycardia

296
Q

Medical management of ascites

A

Salt restriction and diuretics (furosemide and spironolactone)
Paracentesis if tense ascites, SOB, or early satiety

297
Q

Definition of constipation (Rome criteria)

A

Straining
Lumpy hard stools
A sensation of incomplete evacuation
Use of digital maneuvers
A sensation of anorectal obstruction or blockage with 25 percent of bowel movements
A decrease in stool frequency (less than three bowel movements per week)

For three months starting six months ago

298
Q

One must consider differential for constipation over 50

A

Colorectal cancer

299
Q

Workup and management for constipation

A

CHeck for opioid use
CBC, CMP, TSH
Increase fiber
Laxatives Metamucil (Bulk forming)>Polyethylene glycol (Osmotic)>Stimulant/Suppository/Stool softeners

300
Q

4 pathogens to suspect in daycare diarrhea

A

Rotavirus, Cryptosporidium, Giardia, Shigella

301
Q

Cruise ship diarrhea

A

Norovirus

302
Q

Picnic/Egg salad diarrhea

A

Staph aureus

303
Q

Seafood diarrhea

A

Cholera (rice water stools), V. Parahemolyticus

304
Q

Raw ground beef or seed sprouts diarrhea

A

Salmonella

305
Q

Home canning diarrhea

A

C. perfringens
C Botulinum

306
Q

HIV diarrhea

A

Cryptosporidium

307
Q

Presentation of diverticulitis

A

Left sided appendicitis
Fever/chills/Nausea/vomiting/left-sided abdominal pain

308
Q

Dx of diverticulitis

A

CT with oral, rectal, and IV contrast; do colonoscopy 1 to 3 months after the episode to look for cancer.
CT revealing fat stranding and bowel wall thickening

309
Q

Management of diverticulitis

A

Pain control and liquid diet
May us abx
Metamucil and HIgh fiber diet to prevent

310
Q

2 Medications that can cause esophagitis

A

NSAIDs or Bisphosphonates

311
Q

Management of esophageal candidiasis

A

Fluconazole 100 mg PO Daily

312
Q

HSV v CMV esophagitis and managment

A

HSV - Punch lesions use acyclovir
CMV - Large solitary ulcers use gancyclovir

313
Q

Management of corrosive esophagitis

A

Steroid

314
Q

Management of eosinophilic esophagitis

A

Allergen elimination
Steroid topical of inhaled

315
Q

Prevention of bisphosphonate indiced esophagitis

A

Take with water avoid reclining for 30-45 minutes

316
Q

General presentation of gastritis

A

Dyspepsia (belching, bloating, distension, and heartburn) and abdominal pain are common indicators of gastritis

317
Q

DIagnosis, Location and management of H. Pylori gastritis

A

LOcated in the antrum and body of the stomach
Breath or fecal antigen test
CAP (Clarithromycin, Amoxicillin, PPI0 4-8 weeks
OR quad therapy (PPI, Pepto, 2 ABX

318
Q

Dividing line for upper/lower GI bleeds

A

Ligament of trietz

319
Q

6 potntial causes of an upper GI bleed

A

Peptic ulcer: upper abdominal pain
Esophageal ulcer: odynophagia, gastroesophageal reflux, dysphagia
Mallory-Weiss tear: emesis, retching, or coughing prior to hematemesis
Esophageal varices with hemorrhage or portal hypertension: jaundice, abdominal distention (ascites)
Malignancy (gastric cancer and right-sided colon cancer): dysphagia, early satiety, involuntary weight loss, cachexia
Severe erosive esophagitis: odynophagia (painful swallowing), dysphagia and retrosternal chest pain

320
Q

Management of upper GI bleeds

A

NPO
Fluids
Oxygen
IV PPI until cause determined

321
Q

Blood transfusion thresholds

A

Under 9 in high risk pts (ie. elderly, CAD)
Under 7 in everybody else

322
Q

6 causes of lower GI bleeds

A

Hemorrhoids: painless bleeding with wiping
Anal fissures: severe rectal pain with defecation
Proctitis: rectal bleeding and abdominal pain
Polyps: painless rectal bleeding, no red flag signs
Colorectal cancer: Painless rectal bleeding and a change in bowel habits in a patient 50-80 years of age
Diverticulosis is generally an incidental finding since diverticular bleeding is usually of greater volume

323
Q

Presentations, DIagnosis and Management of GIardiasis

A

Drinking stream water hx
Bulky foul smelling stool without blood
DX: Stool sample cyst or trophozoites
TX with tinidazole (first line)
Flagyl (Metronidazole) 250-750 mg PO TID
Symptoms resolve within 5-7 days

324
Q

Presentation, management, and diagnosis of enterobiasis

A

Pinworm
Perianal pruritis worse at night
Peds
Scotch tape test with egg visualization under microscopy
TX with mebendazole or pyrantel pamoate

325
Q

Presentation, management and diagnosis of Taeniasis (Tapeworm)

A

GI sx and weight loss
B12 defdiciency with hx of undercooked meat consumption
Tape test for D. latum, stool for eggs
Tx: Praziquantel

326
Q

Presentation, diagnosis and management for hookworm

A

Cough, weight loss, anemia, recent travel, anemia
Hx of serpigionous rash (foot to lungs to GI)
Stool for adult worms
TX: mebendazole or pyrantel

327
Q

Presentation, diagnosis, and management of roundworm

A

Pancreatic duct, common bile duct, and bowel obstruction, myalgia
Ate bear meat
MC helminth worldwide
Stool sample for eggs and adult worms
TX: albendazole, mebendazole, pyrantel pamoate

328
Q

Presentation, diagnosis, and management of amebiasis

A

Bloody diarrhea and tenesmus, liver abcess,
Stool for trophozooites
Iodoquinol or paromomycin
Flagyl for liver abscess

329
Q

Presentation, diagnosis and management of schistosomiasis

A

Contaminated fresh water - penetrate the skin and spread through the body
Rash, abdominal pain, diarrhea, bloody stool, or blood in the urine
DX: Eggs in urine or feces
TX: Praziquantel

330
Q

Diagnosis and management for heartburn

A

Mild/Self limiting symptoms do not require further workup unless long standing or resistant to PPI therapy
Standard workup:
Endoscopy with biopsy is the gold standard for diagnosis
Manometry
24-hour ambulatory pH probe testing
Barium esophagography
Step up therapy H2 blockers to PPI

331
Q

Zollinger Ellison syndrome

A

Gastrin secreting tumor - resect and PPI

332
Q

Presentation of GI and esophageal cancer

A

Esophagus - Progressive dysphagia to solids with weight loss, hematemesis
GI - Abdominal pain and unexplained weight loss, Dyspepsia, N/V, early satiety

333
Q

Presentation, diagnosis and management of external hemorrhoids

A

Hx of hematochezia, straining, constipation
Below dentate line
Anoscopy
Purple with extreme pain, may not bleed iif thrombosed
Thrombosed = Excise
Non-thrombosed = Conservative therapy (sitz bath, anesthetic, fiber)

334
Q

Presentation and management of internal hemorrhoids

A

Above dentate line
Bright red blood per rectum, pruritus and rectal discomfort
Tx: Fiber, sitz bath, ice packs, bed rest, stool softeners, topical steroids
Rubber band ligation If protrudes with defecation, enlargement, or intermittent bleeding
Closed hemorrhoidectomy if permanently prolapsed

335
Q

WHen to refer an umbilical hernia to surgery

A

WHen it continues beyond two years

336
Q

Direct v Indirect inguinal hernia

A

Indirect through the internal inguinal canal - may enter scrotum, more likely to than direct
Direct through external canal at hesselbach’s triangle

337
Q

3 types of hernia entrapments

A

Strangulated hernia: A hernia becomes strangulated when the blood supply of its contents is seriously impaired

Obstructed hernia: This is an irreducible hernia containing intestine that is obstructed from without or within, but there is no interference to the blood supply to the bowel

Incarcerated hernia: A hernia so occluded that it cannot be returned by manipulation, it may or may not become strangulated

338
Q

Presentation, diagnosis, and management of Ulcerative COlitis

A

Most common in the rectum
Shallow - mucosa only
Hematochezia and pus-filled diarrhea, fever, tenesmus, anorexia, weight loss
Barium enema: Lead pipe appearance (loss of haustral markings) -> may lead to toxic megacolon
P-ANCA on serology
Colonoscopy: continuous lesions in the mucosa/submucosa of rectum and colon
Colectomy is curative
Medications: Prednisone and mesalamine

339
Q

Presentation, diagnosis, and management of crohn’s disease

A

Mouth to anus- most common in the terminal ileum
Deep skip lesions
Fistulas common, abscess
Abdominal pain, aphthous ulcers, weight loss, nonbloody diarrhea, and cramping
Barium enema: Cobblestone appearance
Colonoscopy: focal ulcerations alternating with normal mucosa
Flares: Prednisone +/- Mesalamine +/- Metronidazole or Ciprofloxacin
Maintenance: Mesalamine
NO SUrgery

340
Q

Presentation, diagnosis and management of toxic megacolon

A

Septic and febrile with abdominal pain
Distended colon, more common with UC than Crohns
Decompression and potential colon resection

341
Q

Presentation of ischemic bowel disease and MC site

A

MC site - SMA
History of coronary artery disease experiencing recurrent cramping with postprandial abdominal pain
Pain 10-30 mins after eating, relieved by lying or squatting
Few PE findings

342
Q

DIagnosis of bowel ischemia

A

Mesenteric angiography is considered the gold standard
Abdominal X-ray shows “thumb-printing” of small bowel or right colon due to submucosal bleeding

343
Q

Management of bowel ischemia

A

Supportive: Bowel rest, fluids, antibiotics
Laparotomy with bowel resection for bowel infarction
Revascularization is the gold standard

344
Q

First Sign of Jaundice

A

Scleral icterus

345
Q

Serum billirubin of jaundice

A

Serum bilirubin > 2.5 mg/dl

346
Q

Prehepatic Jaundice

A

Hemolytic
Increased indirect/unconjugated bilirubin, mild hyperbilirubinemia
Dark urine due to hemoglobinuria; dark stool

347
Q

Intrahepatic Jaundice

A

Increased indirect and direct bilirubin; ALT and AST markedly elevated
Dark urine = increased direct bilirubin
ETOH hepatitis: AST > ALT 2:1
Acute hepatitis: increased ALT and AST > 1000; ALT >AST usually
Chronic hepatitis: increased ALT: AST but <500

348
Q

Posthepatic jaundice

A

Obstructive
Cholestasis = bile duct blockage ⇒ increased conjugated bilirubin
Cholestasis / pancreatic CA
Increased direct/ conjugated hyperbilirubinemia
GGT and ALP elevated
Dark urine = increase direct bilirubin
Acholic stools = biliary obstruction (white)

349
Q

Presentation, diagnosis and management of a mallory weiss tear

A

Caused by forceful vomiting. Associated with alcohol use, upper
Endoscopy showing superficial longitudinal mucosal erosions. Hematemesis.
Treatment: Supportive. May cauterize or inject epinephrine if needed

350
Q

6 Potential causes of melena

A

Gastric cancer,
Duodenal ulcers,
Right-sided colon cancer,
Portal hypertension with esophageal varices,
Severe erosive esophagitis,
Mallory-Weiss syndrome.

351
Q

7 potential causes for hematochezia

A

Hemorrhoids,
Anal fissures,
Polyps,
Proctitis,
Rectal ulcers, and
Colorectal cancer.
Diverticulosis is generally an incidental finding since diverticular bleeding is usually of greater volume

352
Q

Eight potential causes of nausea

A

Gastroenteritis: nausea, vomiting, diarrhea, stomach cramps
Migraine headache: nausea, vomiting, headache
Food poisoning: nausea, vomiting, malaise
Influenza virus: nausea, vomiting, cough with phlegm
Pyloric Stenosis: Infant with projectile vomiting
Peptic ulcer disease: upper abdominal pain, may have nausea or vomiting
Hiatal hernia: symptoms of GERD
Common cold: nausea, vomiting, runny nose

353
Q

Management of nausea

A

Standard nausea meds:
Scopolamine patch,
Dexamethasone (4mg),
Ondansetron (4mg)

Rescue anti nausea:
Prochlorperazine,
Droperidol

354
Q

GI cocktail (3 ingredient) and test of nausea in ED

A

Maalox, viscous lidocaine, droperidol

PO challenge in ED – eat something before going home ⇒ can be performed with GI cocktail

355
Q

MCC of small bowel obstruction

A

Postoperative adhesions - adults
Intussussception - Peds

356
Q

Presentation of SBO

A

Typically in ileum or jejunum (hint that most of the small bowel)
Symptoms include colicky abdominal pain, nausea, bilious vomiting, abdominal distention, and diarrhea
High-pitched hyperactive bowel sounds (early) progressing to silent bowel sounds (hypoactive bowel sounds -late)
Dehydration + electrolyte imbalances

357
Q

Diagnosis of SBO

A

KUB shows dilated small bowel loops (< 3 cm), air-fluid levels in the small bowel with valvulae conniventes visible across the full width of the bowel, string of pearls (multiple air-fluid levels), and paucity of gas in the colon
CT for follow up

358
Q

Management of SBO

A

Treat with decompression with an NGT, surgery if a mechanical obstruction is suspected

359
Q

MCC and setting of Large Bowel Obstruction

A

Cancer - COlon or rectum

360
Q

Presentation of LBO

A

Gradually increasing abdominal pain with longer intervals between episodes of pain, abdominal distention, constipation, less nausea and vomiting (may be delayed) - late-onset feculent vomiting, blood in stool, more common in the elderly
May be febrile/tachycardic/dehydrated/electrolyte imbalanced

361
Q

Diagnosis of LBO

A

KUB shows dilated colon (> 5 cm), air-fluid levels in the colon, haustra (small pouches caused by sacculation, which give the colon its segmented appearance) that do not transverse bowel, bird beak sign: narrowing of the lumen at the site of obstruction
CT after

362
Q

Management of LBO

A

Bowel rest, NG tube placement, surgery as directed by the underlying cause

363
Q

Vomiting and bowel obstruction

A

More common in SBO

364
Q

Pain in bowel obstruction

A

SBO - Shorter and more frequent cramps
LBO - Longer and less frequent cramps

365
Q

Duodenal vs. Gastric ulcer - how to tell the difference

A

Duodenal - Pain decreases with eating, 90% of ulcers, 95% are H. Pylori
Gastric - Pain increases with eating, 10% of ulcers, often H pylori, Gnawing or burning pain

Bleeding is MC complication of both

366
Q

Diagnosis of PUD

A

Upper endoscopy with ulcer biopsy for H pylori and neoplasia

367
Q

Management of PUD

A

PPI for 4-8 weeks
CAP therapy for H. pylori
In active bleeding, a negative bipsy does not exclude H. pylori - a breath test or stool test may be needed
Eradication confirmation 4+ weeks after therapy completion.

368
Q

MCC and presentation of bronchiolitis

A

RSV = MCC
Wintermonths
Infants and young children
Tachypnea, respiratory distress, wheezing

369
Q

Dx of bronchiolitis

A

DX: Nasal washing for RSV culture and antigen assay; CXR = normal

370
Q

Management of bronchiolitis
Most effective/only therapy
5 indications for hospitalization

A

Oxygen is only therapy shown to improve
Hospitalization if
O2 saturation < 95-96%,
Age <3 months,
RR > 70, Nasal flaring,
Retractions, or
Atelectasis on CXR
Steroids, Bronchodilators, Ribavirin, Monoclonal Ab’s may help if severe or immune compromised

371
Q

Presentation of acute bronchitis

A

Cough for > 5 days lasting 1-3 weeks total
Cough, fever (unusual), constitutional symptoms
Typically, it is less severe than pneumonia, with normal vital signs, no rales, no egophony

372
Q

MC agents of acute bronchitis

A

Most common - viral (95%)
Common bacterial = M. catarrhalis
Chronic lung patients: H. influenzae, S. pneumoniae, M. catarrhalis

373
Q

Diagnosis of acute bronchitis

A

DX: Obtain CXR if the diagnosis is uncertain or symptoms persist despite conservative treatment

374
Q

Management of acute bronchitis

A

Supportive tx, steroids in those with preexisting lung disease - hydration, expectorant, analgesic, B2 agonist, cough suppressant
Hospitalize if O2 under 96%
Antibiotics are indicated in the elderly, underlying cardiopulmonary disease, cough >7-10 days, or immunocompromised - Azithromycin/Clarithromycin

375
Q

Presentation of epiglottitis

A

Haemophilus influenzae type B (Hib)
Usually in unvaccinated children
Tripod with dysphagia, drooling, and respiratory distress

376
Q

Diagnosis of epiglottitis

A

Thumbprint sign on Lateral XR
Culture for H. flu
CT scan shows narrow airway
Definitive = laryngoscopy with cherry red epiglottis

377
Q

Management of epiglottitis

A

Intubation, supportive care
Rocephin
May treat outpatient if stable

378
Q

MOA of ARDS

A

⇑ Permeability of alveolar-capillary membranes ⇒ development of protein-rich pulmonary edema (non-cardiogenic pulmonary edema)
ARDS can occur in those who are critically ill or who have significant injuries ⇒ sepsis (most common), severe trauma, aspiration of gastric contents, near-drowning

379
Q

Presentation of ARDS

A

Rapid onset of profound dyspnea occurring 12-24 hours after the precipitating event
Tachypnea, pink frothy sputum, crackles

380
Q

Diagnosis of ARDS

A

CXR shows air bronchogram and bilateral fluffy infiltrate

381
Q

Management of ARDS
PaO2 and SAO2 goals

A

Tracheal intubation with the lowest level PEEP to maintain PaO2 >60 mmHg or SaO2 >90
ARDS is often fatal. The risk increases with age and the severity of illness

382
Q

Diagnosis of asthma

A

REVERSIBILITY!!
Spirometry with pre and post-therapy (albuterol inhalation) readings
Decreased FEV1/FVC (75-80%)
> 10% increase of FEV1 with bronchodilator therapy

383
Q

Acute asthma treatment - 4 things

A

Oxygen,
Nebulized SABA (albuterol, etc.)
Ipratropium bromide, and
Oral steroids

384
Q

Presentation and MCC of croup

A

Infection of the upper airway, which obstructs breathing and causes a characteristic barking cough and stridor
Caused by the parainfluenza virus

385
Q

Diagnosis of croup

A

Steeple sign on CXR

386
Q

Management of croup

A

Supportive (air humidifier), antipyretics
Severe: IV fluids and nebulized racemic epinephrine, steroids

387
Q

Presentation of FB aspiration

A

Inspiratory stridor (high) or wheezing (low)
Elevated temp and pulse, some decreased breath sounds (lobar)
Choking/Gagging
Hx of institutionalization, sedation, alcohol

388
Q

Dx of FB aspiration

A

Mediastinal shift and hyperinflation shown on CXR - may also see FB
ABG to assess ventilation

389
Q

More common location for foreign body inhalation

A

Right main stem bronchus over left

390
Q

Management of FB inhalation

A

Treatment: Remove foreign body with a bronchoscope
Rigid bronchoscopy is preferred in children, while flexible is diagnostic and therapeutic in adults

391
Q

3 MCC of hemoptysis

A

Bronchitis (50%): hemoptysis, dry cough, cough with phlegm
Tumor mass (20%): hemoptysis, chest pain, rib pain, tobacco history, weight loss, clubbing
Tuberculosis (8%): hemoptysis, chest pain, sweating

392
Q

Diagnostics for hemomptysis patients

A

Cytology (especially when worried about lung cancer)
Fiberoptic bronchoscopy is preferred for CA tissue biopsy, bronchial lavage, or brushing
Rigid bronchoscopy for cases of massive bleeding because of its greater suctioning and airway maintenance capabilities
High-resolution CT gives a greater positive yield of pathology - can’t r/o cancer with an XR

393
Q

Management of hemoptysis

A

ABC’s

394
Q

DIagnosis and Management of influenza

A

Rapid antigen test to dx
BIlateral diffuse infiltrates on CXR
Zanamivir or Oseltamivir within 48 hours of symptoms
Antivirals reduce illness by 1 day

395
Q

Presentation of Small cell lung cancer

A

15% of lung cancer cases with 99% being smokers
Recurrent pneumonia with anorexia, weight loss, and weakness

396
Q

Associated s/s of small cell lung cancer

A

Superior vena cava syndrome
Laryngeal nerve palsy
Horner syndrome
Malignant pleural effusion
Digital clubbing
Eaton lambert syndrome

397
Q

Eaton lambert syndrome

A

MC in SCLC
Similar to myasthenia gravis (proximal muscle weakness/fatigue, diminished DTRs, paresthesias (lower extremity)

398
Q

Diagnostics of SCLC

A

CXR is most important for DX
CT chest with IV contrast for staging
Definitive - Tissue biopsy—determine the histologic type
Cytologic examination of sputum if central tumor

399
Q

Management and prognosis for SCLC

A

Combination chemotherapy with 10-13% survival rate
CANNOT be treated with surgery

400
Q

3 types of NSCLC

A

Squamous cell 25-35%
Large cell - 5%
Adenocarcinoma - 35-40%

401
Q

Presentation of squamous cell carcinoma

A

Central
May cause hemoptysis
Hypercalcemia with elevated PTH

402
Q

Presentation of large cell lung cancer

A

Rapid growth with response to surgery
60% are peripheral
Gynecomastia

403
Q

Presentation of lung adenocarcinoma

A

Peripheral - associated with smoking and asbestos
Peripheral with thrombophlebitis

404
Q

Management for NSCLC

A

Stage 1-2 surgery
Stage 3 Chemo then surgery
Stage 4 palliative

405
Q

Management of a pulmonary nodule

A

If suspicious (depending on radiographic findings below) will need a biopsy
Ill-defined lobular or spiculated suggests cancer
If not suspicious < 1 cm, it should be monitored at 3 mo, 6 mo, and then yearly for 2 yr
Calcification, smooth, well-defined edges, suggest benign disease

406
Q

Presentation of pertussis

A

Severe hacking cough followed by a high-pitched intake of breath that sounds like a whoop.
Consider in adults with 2+ week cough and peds under 2 y/o

407
Q

Diagnosis and management of pertussis

A

Nasopharyngeal swab
Treat with a macrolide (gram negative) and b2 agonsit

408
Q

Presentation of pleural effusion

A

Presents with dyspnea and a vague discomfort or sharp pain that worsens during inspiration

409
Q

Lights criteria for pleural effusion

A

Determine if the pleural fluid is exudative by meeting at least one of Light’s Criteria (increased protein, increased LDH)
Pleural fluid protein / Serum protein >0.5
Pleural fluid LDH / Serum LDH >0.6
Pleural fluid LDH > 2/3

410
Q

Transudative Causes Vs. Exudative Causes

A

Trans - Hydrostatic pressure, liver, etc.
Ex - Infection, cancer

411
Q

Dx of pleural effusion

A

Lateral decubitus XR
Thoracocentesis = gold standard to treat
PLeurodesis for recurrent or drains

412
Q

4 causes of pleuritic chest pain and definition

A

Characterized by sudden and intensely sharp, stabbing, or burning pain in the chest when inhaling and exhaling
Pneumonia
Pericarditis
Pericardial effusion
Pancreatitis

413
Q

Causes of viral pneumonia in kids and adults

A

Kids - RSV
Adults - Flu

414
Q

Presentation, dx, and management of bacterial pneumonia

A

fever, dyspnea, tachycardia, tachypnea, cough, +/- sputum

Dx: patchy, segmental, lobar, multilobar consolidation; blood cultures x2, sputum gram stain
Tx: outpatient = doxy, macrolides; inpatient = ceftriaxone + azithromycin/respiratory FQs

415
Q

Coccidiodmycosis

A

Non-remitting cough/bronchitis non-responsive to conventional tx
Fungal inhalation in western states; test with EIA for IgM and IgG
Tx: fluconazole / itraconazole

416
Q

Pulmonary aspergillosis

A

Usually those with healthy immune systems
Tx: fluconazole / itraconazole

417
Q

Cryptococcus

A

Found in soil; can disseminate and à meningitis
Lumbar puncture for meningitis
Tx: amphotericin B

418
Q

Histoplasmosis

A

Pulmonary lesions that are apical and resemble cavitary TB; worsening cough and dyspnea, progression to disabling respiratory dysfunction; no dissemination
Bird or bat droppings (caves, zoo, bird); Mississippi Ohio river valley
Signs: mediastinal or hilar LAD (looks like sarcoid)
Tx: amphotericin B

419
Q

CD4 threshold for pneumocystis jirovecci

A

Under 200

420
Q

Diagnosis and management for pneumocystis jirovechi pneumonia

A

CXR: diffuse interstitial or bilateral perihilar infiltrates
Dx: bronchoalveolar lavage PCR, labs, HIV test; low O2 sat despite supplemental oxygen
Tx: Bactrim and steroids; pentamidine for allergy
Prophylaxis for high risk pt with CD4 <200 = daily Bactrim

421
Q

CURB-65 scoring

A

Confusion,
Urea >7,
RR >30,
Systolic BP < 90 mmHg or Diastolic BP ≤ 60 mmHg,
Age >65

422
Q

CURB-65 interpretation

A

0-1 = low risk, consider home tx
2 = probable admission vs close outpatient management
3-5 admission, manage as severe

423
Q

General presentation of a pneumothorax

A

Acute onset ipsilateral chest pain and dyspnea with decreased tactile fremitus, deviated trachea, hyperresonance, diminished breath sounds

424
Q

Diagnosis for pneumothorax

A

Those who are unstable should have rapid bedside imaging with pleural ultrasonography (highly sensitive and specific)
Those with a stable presentation can wait for confirmation by chest radiography - expiratory chest film reveals pleural air
CT scan if uncertain, hypoxemia on ABG

425
Q

Management of small pneumothorax

A

Under 15%
Will resolve spontaneously

426
Q

Management of large pneumothorax

A

Chest tube placement

427
Q

Management of tension pneumothorax

A

Large bore needle decompression

428
Q

Management for all pneumothoraces

A

CXR every 24 hours until resolved

429
Q

EKG of a PE

A

TACHYCARDIA (most common),
S1Q3T3 (rare),
Non-specific ST wave changes

430
Q

Initial and definitive diagnostics for PE

And 2 CXR signs

A

Spiral CT - Initial
Pulmonary angiography - Definitive

CXR: Westermark sign or Hampton hump (triangular or rounded pleural base infiltrate adjacent to hilum)

431
Q

Management of a PE

A

Heparin followed by DOAC

432
Q

3 MCC of SOB

A

COPD
Asthma
CHF

433
Q

DIagnosis for SOB - 6 s/s

A

Respiratory rate<10 or >25
Weak respiratory effort
Oxygen saturation<92% on room air or <95% on high concentration oxygen
Hypercapnia (elevated CO2 in ABG)
Decrease level of consciousness
Exhaustion

434
Q

Management for SOB - 6 pearls

A

Oxygen (high flow nasal canal or rebreathing mask)
Albuterol for asthma and COPD
Lasix for CHF
BIPAP for respiratory difficulty and low O2 saturations
Intubation for severe cases

435
Q

> 5 mm positive tuberculin testers

A

At high risk, fibrotic changes on CXR, immunocompromised HIV/drugs, steroids/TNF antagonists daily, or close contact with pt with infectious TB

436
Q

> 10 mm positive tuberculin testers

A

In patients age < 4 or some risk factors = hospitals and other healthcare facilities, IVDU, recent immigrants from high prevalence area, renal insufficiency, prison, homeless shelter, diabetes, head/neck cancer, gastrectomy/jejunoileal bypass surgery

437
Q

> 15 mm positive tubercuulin testers

A

Everyone

438
Q

Sputum smears for TB

A

Need 3 negative AFB smears to be considered negative

BBiopsy shows caseating granulomas

439
Q

Management of latent TB - 3 regimens

A

Positive PPD with negative CXR
Three months of once-weekly isoniazid plus rifapentine (3HP)
Four months of daily rifampin (4R)
Three months of daily isoniazid plus rifampin (3HR)

440
Q

Rifapentine-Moxy therapy for TB

A

Active
High-dose daily rifapentine (RPT) with
Moxifloxacin (MOX): QT-prolonging agent and has been associated with cardiac arrhythmias, which may be fatal
Isoniazid (INH) and
Pyrazinamide (PZA)

441
Q

Quad therapy (RIPE) for TB

A

Rifampin (RIF): Orange body fluids, hepatitis - “remember R = red/orange body fluids”
Isoniazid (INH): peripheral neuropathy (give with B6 - pyridoxine 25 to 50 mg/day)
Pyrazinamide (PZA): Hyperuricemia (Gout)
Ethambutol (EMB): Optic neuritis, red-green blindness - “remember E = eyes”

442
Q

Management of altered mental status

A

Naloxone is opiate OD suspected
ABC’s
Thiamine and dextrose

443
Q

GCS Eye scores

A

Eye-opening:

4- spontaneous
3- voice
2-pain
1-none

444
Q

GCS Verbal scores

A

Verbal:

5-oriented
4-confused
3-inappropriate words
2-incomprehensible
1-none

445
Q

GCS Movement scores

A
  1. Motor:

6-obeys commands
5-localizes pain
4-withdraws
3-abnormal flexion (decorticate)
2-abnormal extension (decerebrate)
1-none

446
Q

GCS threshold for intubation

A

8 or less

447
Q

3 pathologies of paresthesia with worup

A

Diabetes (very common due to the destruction of the nerves due to the elevated glucose)
Nerve root pathology ( impingement and compression of the nerves)
Central pathology (Brain causes such as Multiple Sclerosis, CVAs, etc.)

CT/MRI

448
Q

Presentation of Bell’s palsy

A

Unilateral facial nerve paralysis with no other findings
Peak in 48 hours with viral prodrome
NOT FORHEAD SPARING
Keratitis from inability to close eyes

449
Q

Management and of Bell’s Palsy

A

Treatment is prednisone, artificial tears, tape eyelid shut
Comments: Bilateral: Lyme disease, infectious mononucleosis

450
Q

Presentation of encephalitis

A

Clinically differentiated from meningitis due to altered brain functioning
HSV MC, with CMV MC in immunecompromised
Flu-like illness folloed by fever, headahce , seizure, and AMS

451
Q

Diagnosis of encephalitis

A

lumbar puncture and MRI
PCR for viruses
Kernig’s and Brudzinski’s usually absent

452
Q

Management of encephalitis

A

Supportive care and acyclovir 10 mg/kg IV q8hr started promptly

Empiric antibiotics are often given until bacterial meningitis is excluded

453
Q

Presentation of status epilepticus (2 potential criteria)

A

> or equal to 5 min continuous seizure activity or more than one seizure without recovery from the postictal state in between episodes

454
Q

Management of status epilepticus

A

Place in left lateral decubitus position
Benzo - 1st line
Phenytoin - 2nd line
Phenobarbitol or lacosamide - 3rd line
Watch for resolution of acidosis post

455
Q

Management for focal seizures

A

Phenytoin or Carbamazepime
May or may not loose consciousness (simple v. complex)

456
Q

EEG and Management of absence seizures

A

EEG ⇒ brief 3-Hz, spike, and wave discharge
Tx: ethosuximide

457
Q

8 other types of seizures

A

Tonic-clonic: convulsive (grand mal) – bilaterally symmetric and without focal onset, begins with LOC
Tonic phase: very stiff and rigid 10-60 seconds, clonic phase = convulsions, post-ictal phase= confused state
Atonic = drop attack ⇒ like syncope; loss of muscle tone
Clonic: loss of control of bodily function, jerking, may temporarily lose consciousness
Tonic: extreme rigidity then LOC
Myoclonic: muscle jerking, no tonic phase, occurs in the morning
Febrile: temp >38 C, >6mo, <5 years, absence of CNS infection / inflammation
Infantile spasm: type of epilepsy seizure
Psychogenic non-epileptic seizure: not due to epilepsy but look similar to an epileptic seizure

458
Q

Presentation of epidural hematoma

A

Transient loss of consciousness following injury
LUCID with headache and one sided weakness
MC - Middle meningeal artery bleed

459
Q

Diagnosis and management of an epidural hematoma

A

Non-contrast CT showing a lens shape
May also see a skull fracture

Surgical craniotomy / medical management of increased intracerebral pressure (mannitol, hyperventilate, steroids/ventricular shunt)

460
Q

Presentation of a subdural hematoma

A

Head injury followed by neurological symptoms - often seen in the elderly or in alcoholics with hx of falls

461
Q

Dx and management of subdural hematoma

A

Non-contrast CT scan showing crescent shaped bleed
Observe if small
Surgery ⇒ burr hole trephination, craniotomy, craniectomy

462
Q

ANterior cord syndrome

A

Loss of pain/temperature below the level of the lesion preserved joint position/vibration

463
Q

Central cord syndrome

A

Loss of pain and temperature sensation at the level of the lesion, where spinothalamic fibers cross the cord with other modalities preserved (dissociated sensory loss)

464
Q

Cord transection syndrome

A

Rostral zone of spared sensory levels (reduced sensation caudally, no sensation in levels below injury); urinary retention and bladder distension

465
Q

Brown Sequard syndrome (cord hemisection

A

Loss of joint position and vibration sense on the same side as the lesion and pain/temperature on the opposite side a few levels below the lesion

466
Q

Presentation of Guillain-Barré syndrome

A

Ascending paralysis after immunization or infection (C. jejune, CMV, EBV)

467
Q

Diagnosis and management of Guillain Barre

A

Lumbar puncture ⇒ elevated CSF protein with normal CSF WBC
Tx: plasma exchange (remove circulating antibodies) and IVIG
Monitor PFTs for paralysis of chest muscle/diaphragm (respiratory failure)
Good prognosis

468
Q

Presentation of concussion

A

Mild TBI with potential loss of consciousness less than 30 minutes
GCS 13-15
Amnesia, HA, Nausea, vomiting

469
Q

Diagnosis of a concussion

A

Use validated clinical decision rules to determine if imaging is warranted - No routine imaging of pediatric patients with mTBI
Usually a clinical diagnosis

470
Q

Gradual concussion return 6 steps

A

Step 1: back to regular activities
Step 2: light aerobic exercises – walking stationary cycling no resistance training
Step 3: sports specific exercise – running or skating drills
Step 4: non-contact training drills
Step 5: Full contact practice
Step 6: Return to sports – normal gameplay

471
Q

Most significant risk factor for stroke

A

HTN

472
Q

Commoness of different stroke types

A

Ischemic: 85% - 2/3 thrombotic, 1/3 embolic
Hemorrhagic - 15%

473
Q

Presentation of a stroke

A

Hemiparesis opposite of side of stroke, Hemisenory deficit,

474
Q

Presentation of stroke in the Anterior circulation (anterior cerebral/middle cerebral arteries)

A

Associated with hemispheric s/s (aphasia, apraxia, hemiparesis, hemisensory loss, visual field defect)

475
Q

Presentation of stroke in the posterior circulation (vertebral/basilar arteries):

A

Coma, drop attack, vertigo, n/v, ataxia

476
Q

Presentation of stroke in the carotid/ophthalmic:

A

amaurosis fugax

477
Q

Presentation of stroke in the MCA

A

Aphasia, neglect, hemiparesis, gaze preference, homonymous hemianopsia

478
Q

Presentation of stroke in the ACA

A

Leg paresis, hemiplegia, urinary incontinence

479
Q

Presentation of stroke in the PCA

A

Homonymous hemianopsia

480
Q

Presentation of stroke in the basilar

A

Coma, cranial nerve palsies, apnea, drop attack, vertigo

481
Q

Presentation of stroke in the lacunar

A

Silent, pure motor or sensory

482
Q

Diagnosis of a stroke

A

Non-contrast CT
Transcranial doppler US, echo for ischemic stroke

483
Q

Management of a stroke

A

Thrombolysis, IV admin for rtPA for occlusive disease treat with IV tPA within 3-4.5 hours onset
Admit to ICU or stroke unit with neuro exams every 15 minutes during infusion, every 60 minutes for the next 6 hours then hours 24 hours after tx/get serial blood pressures

484
Q

Ischemic stroke BP control

A

BP closely monitored in first 24 hours; hold antihypertensives until systolic >220 or diastolic >120 with a goal to lower BP by 15% in first 24 hours if tx is indicated
BP has to be <185/110 for thrombolytics ⇒ give labetalol 10-20 mg IV over 1-2 min

485
Q

12 Exclusion criteria for stroke tPA

A

SAH,
Head trauma / prior stroke within 3 mo,
MI within 3 mo,
GI / gastric ulcer within 3 weeks,
Major surgery in 14 days,
Hx of intracranial hemorrhage,
Elevated BP >185 systolic / 110 diastolic,
Active bleeding / acute trauma,
INR >1.7 with anticoagulation,
Glucose <50,
Seizure with postictal state,
Multilobar infarction on CT

486
Q

Presentation, diagnosis and management of a cluster HA

A

Excruciating periorbital pain, lateral/temporal
Ptosis, miosis, lacrimation, conjunctival injection, rhinorrhea, nasal congestion
Occur in clusters
100% oxygen, sumatriptan (prophylaxis: CCBs)

487
Q

Presentation and management of migraine headaches

A

Nausea, photo/phonophobia, aura
Pulsating HA
Abortive tx – triptans, Dihydroergotamine (DHE), antiemetics, NSAIDs
Prophylaxis – beta-blockers, CCBs, TCAs

488
Q

Presentation of Subarachnoid hemorrhage

A

Worst HA of my life with potential sudden LOC
Ruptured berry (saccular) aneurysm accounts for 75% nontraumatic

489
Q

Diagnosis and management of a subarachnoid hemorrhage

A

non-contrast head CT, LP (elevated opening pressure / grossly blood fluid in all 4 tubes
May do cerebral angiography

490
Q

Management of SAH and berry aneurisms

A

Manage BP
Surgical clipping/wrapping of the aneurysm
Anticonvulsants for seizure prevention

491
Q

Presentation, Diagnosis and Management of an intracerebral hemorrhage

A

Usually d/t HTN
abrupt onset of a focal neurologic deficit that worsens steadily over 30 to 90 minutes, altered LOC, stupor, coma, HA, vomiting, and signs of increased ICP
Dx: CT / MRI
Tx: neurosurgery

492
Q

Brain aneurysms DX/TX

A

Saccular aneurysms are almost always the result of hereditary weakness in blood vessels and typically occur within the arteries of the circle of Willis
Diagnosis: Magnetic resonance angiography (MRA) or CT angiography (CTA)
Treatment: Surgical clipping or endovascular coil

493
Q

6 Syncope red flags

A

Syncope during exertion,
Multiple recurrences in short time,
Heart murmur,
Old age,
Significant injury during syncope,
Family history sudden unexpected death

494
Q

5 DDX’s for ataxia

A

Drugs (ETOH) and toxins
Tumors
CVAs
Genetics
B12 deficiency

495
Q

Presentation of a TIA

A

Sudden onset of neurologic deficit, lasting minutes to <1 h (15-30 min on average), a reversal of symptoms within 24 h
10% will have a stroke within 90 days

496
Q

Diagnosis for a TIA

A

CT (without contrast), MRI more sensitive, carotid doppler ultrasound to look for stenosis, CT angiography, MR angiography of neck

Carotid endarterectomy if internal or common carotid artery stenosis is > 70%

497
Q

Management of a TIA

A

Aspirin + dipyridamole or clopidogrel monotherapy (antiplatelet therapy)
ABCD2score: predicts the likelihood of subsequent stroke within 2 days
30% of those with CVA had TIA; the risk is highest 24 hours after the initial event

498
Q

Causes of delerium, dementia, and amnesia

A

Dementia (Alzheimer’s)
Delirium (withdrawal or infection)
Amnesia (head injury, CVA, etc.)

499
Q

Reversible and irreversible causes of dementia

A

Irreversible causes: vascular dementia, Creutzfeldt-Jakob
Reversible: depression, B12 deficiency, syphilis, hypothyroidism, NPH, drug use, intracranial mass

500
Q

Management of dementia

A

Tx: cholinesterase inhibitors (donepezil); NMDA antagonists (memantine) à don’t cure, just slow progression

501
Q

Presentation and management of BPPV

A

Positional, no hearing loss, tinnitus, ataxia, dx: Dix-Hallpike test; tx: Epley maneuvers, meclizine

502
Q

Management of vestibular neuritis

A

Not positional, no hearing loss/tinnitus, tx: meclizine

503
Q

Presentation and management of labrynthitis

A

Acute, self-resolving episode; vertigo, hearing loss tinnitus, tx: meclizine + steroids

504
Q

Presentation and management of meneirre’s disease

A

Chronic, relapsing, remitting; vertigo + hearing loss + tinnitus; tx: diuretics, salt restriction, CN VIII ablation for severe cases

505
Q

Presentation and management of perilymphatic fistula

A

A history of trauma; vertigo from trauma; tx: fix damage surgically

506
Q

Presentation and managment of Acoustic neuroma

A

Ataxia, neurofibromatosis type II, MRI findings: vertigo, hearing loss, tinnitus, and ataxia; tx = surgery

507
Q

Classic Triad of meningitis and presentation

A

fever > 38 C,
nuchal rigidity (stiff neck),
headache
NO AMS

508
Q

Causitive agents of meningitis

A

Aseptic: usually viral; negative blood cultures
Bacterial: community-acquired, usually s. pneumonia (gram + cocci)/n. meningitidis (gram - diplococci) – likely if pt has a rash
Neonates = e. coli / s. agalactiae
>50-60 = listeria / cryptococcus neoformans
Hospital-acquired: staph / aerobic gram-negative

509
Q

Diagnosis of meningitis

A

LP AFTER checking for increased intercranial pressure via CT scan (papilledema is clue for increased ICP)

510
Q

Management of meningitis

A

Aseptic: symptomatic or IV acyclovir for HSV
Bacterial: dexamethasone + empiric IV antibiotics (cephalosporin, Vanco, penicillins)
Household contacts: treat with rifampin, Cipro, Levaquin, azithromycin, ceftriaxone

EOR Exams (5 decks)

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