Emergency Medicine EOR Exam Cards Flashcards
Presentation of Acute bacterial endocarditis
Fever
Often IVDU
New systolic heart murmur (regurg)
Causitive agents of bacterial endocarditis
Acute - S. aureus
Subacute - S. viridans
3 Major Dukes criteria for bacterial endocarditis
Vegetation on Echo
2 blood cultures 12 hours apart
New regurg murmur
Difference of causitive agent and vegetated valve for IVDU v. non-IVDU in bacterial endocarditis
Drug users: Staphylococcus w/ tricuspid veggies
Non-drug users: Streptococcus w/ mitral veggies
4 Minor DUke criteria
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)
Management for bacterial endocarditis including prosthetic valve and prophylaxis for procedures
IV vancomycin or ampicillin/sulbactam PLUS aminoglycoside
Prosthetic valve: Add rifampin
High-Risk patients prophylaxis for procedures: Amoxicillin
Presentation and management of stable angina
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
Presentation of unstable angina
Previously stable and predictable symptoms of angina that are now more frequent, increasing, or present at rest
Diagnosis and mangement of unstable angina
Admit for continuous cardiac monitoring
Stress test if symptoms resolve
MONA
Antiplatelet, BB, LMWH
Presentation and management of prinzmetal angina
Smoking is #1 risk factor, cocaine abuse also risk factor
May see U waves
No reduction in exercise capacity
Transient ST elevation
Management for prinzmetal angina
Stress test or heart cath (no clot found)
IV nitrates
Propranolol = Contrindicated
CCB and long acting nitrates to treat
Common complaints for heart arrhythmias
SOB and Chest Pain
Premature atrial contractions
Early P waves - may not have a QRS
Atrial fibrillation
Irregular heart rate with many foci leading to irregular P waves
Atrial flutter
One foci, sawtoothed P waves between QRS complexes. More regular than A fib
Paroxysmal supraventricular tachycardia
Regular, fast (160 to 220 beats per minute) heart rate that begins and ends suddenly and originates in atria
Accessory pathway tachycardia
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
AV nodal reentrant tachycardia
Most common type of supraventricular tachycardia.
Heart rates 100-250 bpm regular rhythm Late P waves - may be hidden within the QRS
Management of narrow tachycardic arrhythmias
Slowed up with either calcium channel blockers or beta-blockers, adenosine, procainamide, or cardioversion
Management for Wide tachycardic arrhythmias
Cardioversion or amiodarone
Becks triad for cardiac tamponade
Hypotension
Muffled heart sounds
JVD
Other signs of cardiac tamponadeq
Pulsus alternans
Pulsus paradoxus (large drop in BP ~10mmHg with inspiration)
Dx and management of cardiac tamponade
Echo showing diastolic collapse of the right ventricle (an effusion will NOT show collapse)
Pericardiocentesis to treat
5 emergent causes of chest pain
Pericarditis
ACS/MI
PE
Pneumothorax
Aortic Aneurism/Dissection
5 tests to order for chest pain
EKG
Troponin I
BNP
CXR
CBC/CMP
Definition of ventricular tachycardia
Three or more consecutive VPBs, displaying a broad QRS complex tachyarrhythmia
EKG of a LBBB
Bunny ears in V4-6
On side of block
EKG of RBBB
Bunny ears in V1-3
On side of block
Presentation of an NSTEMI
Elevated troponins WITHOUT ST elevation or Q waves
Subendocardial infarct without complete blockage
Troponin as a cardiac biomarker
Most sensitive and specific, appears at 2-4 hours, peaks at 12-24 hours, and lasts for 7-10 days
CK-MB as a cardiac biomarker
Appears at 4-6 hours, peaks at 12-24 hours, and returns to normal within 48-72 hours
Myoglobin as a cardiac biomarker
Less commonly used appears at 1-4 hours. The peak is 12 hours and returns to baseline levels within 24 hours
Management for NSTEMI
Beta Blockers + NTG + aspirin and clopidogrel + heparin + ACEI + statins + reperfusion
NO thrombolysis
Less time sensitive than a STEMI
How a STEMI is different from an NSTEMI
Full thickness infarct with ST elevation/q waves along with biomarker elevation
EKG finding for anterior MI
Q waves and ST elevation in leads I, AVL, and V2 to V6
EKG finding for inferior MI
Q waves and ST elevation in leads II, III, and AVF
EKG finding for lateral MI
ST elevation in the lateral leads (I, aVL, V5-6). Reciprocal ST depression in the inferior leads (III and aVF)
EKG findings for posterior MI
ST depressions in V1 to V3
Time windows for STEMI PCI and Thrombolytics
Give ASA and Plavix immediately
PCI - 90 minutes
THrombolytics - 30 minutesif PCI not available
6 Absolute contraindications to thrombolytic use for an MI
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)
6 Cardiac Causes of DOE
Coronary heart disease
Heart failure
Myocarditis
Pericarditis
MI
ACS
8 Pulmonary causes of DOE
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
6 potential causes of edema
CHF
Kidney disease
Liver disease
Chronic venous disease
Pregnancy
Drugs
Travel
Four treatments for edema
Reduce salt intake
Lasix HTCZ
Compression stockings
Body position (elevate legs)
2 medications that may cause edema
CCB
Alpha 1 blockers -zosin (ie. doxazosin, prazosin…)
Presentation of heart failure
DOE and then with rest
Chronic non-productive cough after lying down
Fatigue
Orthopnea
Nocturnal dyspnea
Nocturia
SIgns of heart failure
Cheyenne stokes breathing (cyclic)
Edema
Rales
S3/S4
JVD
Cyanosis/coolness
Ascites
Diagnostics for CHF
Elevated BNP (lower in obese)
Kerley B lines on CXR
Echo is BEST TEST
NYHA heart classes
I - No limitation
II - Slight limitation
III - Marked limitation
IV - Dyspnea at rest
Management for systolic CHF
HFrEF
ACEI
BB
LOOP DIURETIC
Management for diastolic HF
HfpEF
NO LOOP DIURETIC
ACEI and BB/CCB
Definition and management of hypertensive urgency
BP 180/120+ Without end organ damage
Immediate reduction not needed - start on 2 drug regimen with outpatient follow up
8 Indications of end organ damage (meaning hypertensive emergency)
Retinal hemorrhages
Papilledema,
Encephalopathy,
Acute and subacute kidney injury,
Intracranial hemorrhage,
Aortic dissection,
Pulmonary edema,
Unstable angina or MI
General management of hypertensive emergency
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
Drug of choice for hypertensive urgency
Clonidine
Drug of choice for hypertensive emergency
Sodium nitroprusside
Indication to reduce BP to 140 in the first hour
severe preeclampsia, eclampsia, or pheochromocytoma crisis
Indication to reduce BP to 120 in first hour
Aortic DIssection
Drug of choice for hypertensive retinopathy
Clevidipine or Sodium Nitroprusside
Presentation and management of hypotension
Altered mental status, SBP under 90
Capillary wedge pressure over 15
Fluid and pressors
Definition and management of orthostatic hypotension
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
Indication the orthostatic hypotension is due to low blood volume
Associated with HR increase >15 BPM
7 causes of orthopnea:
3 Cardiac
2 Pulm
2 Other
Cardiac causes:
CHF
MI
Arrhythmias (atrial fibrillation)
Pulmonary causes:`
COPD and cor pulmonale
Pulmonary hypertension
Kidney/Liver failure
Obesity
Arrhythmias causing palpitations - 3
Atrial fibrillation
Wolff-Parkinson-White (WPW) syndrome
Paroxysmal supraventricular tachycardia
Other cardiac conditions causing palpitations - 3
Sick sinus syndrome
MVP
MI
Endocrine and metabolic causes of palpitations - 4
Hypokalemia or Hypomagensemia
Hyperthyroid
Pheochromocytoma
T1DM Hypoglycemia
Drugs causing palpitations - 3+6
Cocaine
Amphetamines
Caffeine
(digoxin, beta-blockers, calcium channel antagonists, hydralazines, diuretics, minoxidil)
Pericardial effusion presentation
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
Presentation of peripheral vascular disease
Hair loss, pallor, cyanosis, brittle nails, black dray ulcers. Hx of atherosclerosis
Diagnostics of peripheral vascular disease
ABI <0.9
Angiography is GOLD STANDARD
Definitive treatment for peripheral vascular disease
Arterial bypass
Medication for peripheral vascular disease
Cilostazol
Aspirin
Plavix
Statins
Syncope - primary cause and technical definition
Not enough blood to brain
Out for seconds with no resuscitation
Loss of postural tone and consciousness
Workup for syncope vs. presyncope
SAME WORKUP
Differential and workup for syncope
Cardiac - Start with this
Neuro - Consider after
Ask to describe dizziness for vertigo vs. lightheadedness
Seizure vs. True Syncope
Seizure has a post-ictal phase, true syncope does not
Presentation of vasovagal syncope
Fainting after seeing blood, etc., w/ prodrome (pallor, nausea, warmth, diaphoresis, blurred vision)
60% of patients with a heart condition
Presentation of cardiac syncope
No prodrome and w/ exercise
Syncope while supine
Presentation of reflex syncope
After exercise with a drop in HR and BP
Presentation of psychogenic syncope
Long lasting, no post ictal phase - suspect
3 potential associated signs of syncope
HA - SAH
Chest Pain - MI, PE
Fever - Sepsis
QT and syncope
Check for meds - Zophran, Psych, Macrolides, FQ, Antipsychotics, Diuretics, nDHP-CCB
May have gone into torsades
EKG of 450+ is concerning
Physical exam for syncope
Head and Neck Trauma
Skin Turgor
Abdomen for AAA
Rectal exam for bleed
Who gets a CT for syncope
Neuro deficit
Trauma to head - Canadian CT rules
How long should syncope last
Less than a minute
Orthostatic syncope presentation
Change in position causes BP to drop causing a reflexive tachycardic response
Carotid sinus syncope
Tight collar, Head turn, Shaving - leading to push on artery
Hx of atherosclerosis
Use carotid massage to dx
Midodrine
Positive dx for carotid sinus syncope
Decrease of SBP by 50+ upon carotid sinus massage
ED care for aortic stenosis
Avoid: Nitro, BB, CCB
Admit for TAVR
Murmur of aortic stenosis
Systolic ejection crescendo-decrescendo at the right upper sternal border
1st post with radiation to the neck
Split S2
Presentation of Aortic stenosis
Murmur is worse with squatting and expiration
Murmur decreases with valsalva
Syncope and LVH
Murmur of Aortic regurg
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
Presentation of aortic regurg
Increases with squatting, decreases with valsalva
History of congenital heart defect or rheumatic fever
Murmur of mitral stenosis
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
Presentation of mitral stenosis
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
Murmur of mitral regurg
Blowing HOLOSYSTOLIC murmur at APEX with a SPLIT S2, radiates to the axilla
Presentation of mitral regurg
Previous STEMI
Low BP with tachycardia
Lung crackles
Presentation of AAA
Pulsatile abdominal mass
Flank pain
Hypotension
Management of AAA
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
Presentation and Diagnostics for Aortic Dissection
Tearing chest pain radiating to the back
Widened mediastinum on CXR
Management for ascending and descending aortic dissections
Ascending aorta- Surgical emergency
Descending aorta- Medical therapy (beta-blockers) unless complications are present
6 P’s of arterial occlusion
Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia
2 MCC of thrombus formation
A-fib
Mitral Stenosis
Diagnosis and management for arterial occlusion
Angiography is gold standard
Treat with IV heparin if not limb-threatening then call the vascular surgeon for angioplasty, graft, or endarterectomy
Presentation of thrombophlebitis
Spontaneous or following IV/PICC line trauma
Pain, erythema, induration, palpable cord
Diagnosis and management of thrombophlebitis
Duplex ultrasound Gold Standard for diagnosis
Treatment: Symptomatic: NSAIDs, warm compress
Presentation of cervical sprain
Stiffness/pain in the neck; presents with paraspinal muscle tenderness and spasm and + Spurling test
Spurling test
Passive cervical extension, Ipsilateral rotation, and Axial compression with pain down the ipsilateral side
Management of a cervical sprain
Soft cervical collar (2-3 days), application of ice /heat, analgesics, gentle active ROM soon after injury
Presentation of thoracic or lumbar back strain
Axial back pain with difficulty bending
No radicular symptoms - pain below the knees
Management for a thoracic/lumbar back strain
Bed rest < 2 days + NSAIDs ± muscle relaxants if no red flag symptoms
6 red flag symptoms of back pain
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
Strain
Involves muscles/ligaments
Sprain
Involves tendons
Olecranon bursitis
Scholar’s elbow
Pain or fever may suggest septic bursitis
Gout also possible etiology
Management of olecranon bursitis
NSAIDs, Rest, Abx, steroid injection, surgery
Prepatellar bursitis
Housemaid’s knee
Pain with direct knee pressure (ie. kneeling)
Often septic in wrestlers
Management of prepatellar bursitis
Compression, NSAID, aspiration, immobilization
Presentation of subacromial bursitis
Often not associated with trauma
Pain with motion and rest
Similar to rotator cuff impingement
3 indications to aspirate subacromial bursitis
Fever
Diabetes
Immune compromise
Presentation of patellar tendonitis
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
Management of patellar tendonitis
Ice, Rest, NSAID
Steroids - CONTRAINDICATED tendon rupture
Presentation of biceps tendonitis
Pain in the bicipital groove
Anterior shoulder pain and pain with resisted supination of the elbow
Popeye deformity = rupture
Management of biceps tendonitis
NSAID, PT, Steroids, surgery if refractory
2 special tests for biceps tendonitis
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.
Presentation of cauda equina
Large midline disk herniation compressing several nerves
Saddle anesthesia, incontinence, paralysis
Diagnosis and management of cauda equina
MRI
SUrgical emergency
Presentation of costochondritis
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
Diagnosis for costochondritis
CRX, Biopsy, EKG, VItamin D to rule out other causes
Management of costochondritis
NSAIDS, Heat, Compression, potentially PT or steroids
Tietze syndrome
Inflammatory process causing visible enlargement of the costochondral area “slipping rib syndrome”
Management and pearls for eccymosis
Ice and NSAIDs
Bruising on an extremity is a fracture until proven otherwise
Pearls for erythema
Erythema is smoke not fire (needs to find underlying cause)
Often indicates that infection needs to be rules out
Humeral Fracture
Nerve commonly injured?
SIgn?
Splint type?
Follow up?
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
Supracondylar Fracture (Humerus right above the condyles)
Common demographic?
Mechanism?
XR Findings?
Nerve and Artery commonly involved?
Splinting?
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)
Nursemaid’s Elbow (Rad Head Subluxation)
Presentation?
Mechanism?
Management technique?
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
Radial Head Fracture
Presentation?
MCC?
Management and splinting?
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
Nightstick Fracture of the Ulna
MCC?
Management for displaced vs. Non displaced?
Usually from a blow; functional brace with good interosseous mold for isolated nondisplaced or distal 2/3 ulna shaft fx; ORIF if displaced
Monteggia Fracture
Definition?
Presentation?
Mechanism?
Potential Nerve Injury?
Management?
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
Galeazzi Fracture
Definition?
Presentation?
MCC?
Management?
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
Colles Fracture
Definition?
Mechanism?
Deformity?
XR view for diagnosis?
Management?
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
Smith Fracture
Definition?
MCC?
Deformity?
Nerve injury?
Management?
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
Management of a snuffbox fracture
Thumb spica splint for 10-12 weeks
Boxer’s Fracture
Definition?
MCC?
Splinting type and degree?
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
Shoulder Fracture
Demographic?
Complication?
Workup?
Management?
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
SHoulder Dislocation MOA
Arm is abducted and externally rotated (FOOSH)
Shoulder dislocation presentation, anterior, posterior
Anterior: MC (arm = anterior) ⇒ arm is abducted and externally rotated (FOOSH)
Posterior: the arm is adducted and internally rotated
Imaging and management of shoulder dislocation
AP, axillary, and scapular view
Reduce, post-reduction films, sling, and swath, PT
Common nerve injury in shoulder dislocation
Axillary nerve
Bankart lesion
Injury of the anterior (inferior) glenoid labrum following a dislocated shoulder
Hill-Sachs Lesion
Dent in the humeral head due to dislocation
Compression chondral injury of the posterior superior humeral head following impaction against the glenoid
Clavicular Fracture
Location MC?
Presentation?
Assoc. MC RC injury?
XR’s to order?
Management?
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
Presentation of a hip fracture
Severe hip or groin pain after a fall
Positive Log Roll maneuver
Pain with active and passive ROM
Main blood supply to femoral neck
Medial circumflex femoral artery
Imaging for a hip fracture
AP X-ray of the pelvis
Look for Avascular necrosis
Management of hip fracture
Manage with ORIF; hip arthroplasty, DVT prophylaxis until ambulatory
More common hip dislocation
Posterior
Presentation of posterior hip dislocation
adducted, flexed, internally rotated
Presentation of anterior hip dislocation
abducted, flexed, externally rotated
One thing to r/o and one thing to prevent in hip dislocation
Sciatic nerve injury
DVT - prevent
X ray results for hip dislocation, anterior v. posterior dislocation
Anterior - Femoral head below acetabulum
Posterior - Femoral head above acetabulum
Management of hip dislocation
Closed reduction, open if failure
XR and neurovascular check after reduction
Ottowa Knee Rules - 5
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
Pittsburgh Knee Rules - 3
SPECIFIC - Rule in
Recent fall or blunt trauma
Age < 12 y/o or > 50 y/o
Unable to take 4 unaided steps
Knee dislocation
Usually after high impact trauma
Concern for popliteal artery injury
CT angiogram to dx
Pre and post XR and MRI
Tibial Plateau Fracture
Usually peds in MVA
Lateral oblique XR
Peroneal nerve check (foot drop)
Nondisplaced - 6-8 weeks cast
Displaced - ORIF
Patellar Fracture
Patella Alta (pulled quad muscles cause fracture displacement; tx = 6-8 weeks immobilization, may bear partial eight; displaced need ORIF
Knee osteoarthritis
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
Ottowa Ankle Rules (3)
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
Jones Fracture
5th metatarsal diaphysis fracture
Lateral foot pain
Due to poor blood supply
AP, Lat, Oblique XR
NWB for 6 weeks
RICE +boot
Most common foot stress fracture
3rd metatarsal - athlete, military
May not show up on XR, may need MRI
Talus fracture
High force impact (falling/snowboarding), X-ray demonstrates talus fracture, non-weight bearing cast for non-displaced, surgery for displaced
Class A Weber ankle fracture
INVERT
Fibular fracture below mortise, tibiofibular syndesmosis intact, usually unstable
Class B Weber ankle fracture
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
Class C Weber ankle fracture
LATERAL PUSH
Fibular fx above Mortise, tibiofibular syndesmosis torn with a widening of talofibular joint, deltoid ligament damage or medial malleolar fracture, unstable = ORIF
Presentation of true gout
Men over 30 (more common in women poste menopause)
Assymmetric tophi - great toe
Pain, swelling redness, tenderness
Podagra
Sudden gout attack
Labs/Diagnostics of gout
Rod shaped negatively birefringent crystals
Serume uric acid over 8
Punched out lesions on XR
Lifestyle modifications for gout
Elevation, rest, decrease purines (meats, beer, seafood, alcohol), weight loss, increase protein, limit alcohol
Management of gout attack
Indomethacin is best
Colcicine (bad GI s/e) or steroids if not tolerated
Meds to avoid in gout
Thiazide diuretics
Aspirin
No allopurinol while acute
2 drugs for long term gout management
Allopurinol
Colchicine
Presentation of pseudogout
Over 60, Large joint involvement without LE tophi
Rhomboid, birefringent, calcium pyrophosphate crystals
Linear calcifications of XR
Management of pseudogout
NSAIDs, colchicine, intra-articular steroid injections
Colchicine = prophylaxis, NSAIDs = acute attacks
C4 herniated disk presentation
May affect the levator scapular and trapezius muscles, resulting in weakness in shoulder elevation. There is no reliable associated reflex.
C5 herniated disk presentation
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.
C6-7 herniated disk presentation
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.
C7-T1 herniation presentation
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.
Sciatica
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
L! Herniation
Rare, causes inguinal pain
L2-L4 hernitation and issues
Older patients with spinal stenosis
Anterior aspect of thigh and knee affected
L5 herniation presentation
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.
S3-4 herniation management
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.
MCC of lower back pain - 2 and time to present
Prolapsed intervertebral disk and low back strain. Usually occurs within 24 hours of injury/overuse
Presentation of back pain
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
Diagnostics for lower back pain
CT, MRI, XR if persistent
Leg lift test
Management of back pain
Short term rest (max 2 days), with support under knees and neck + NSAIDs
Imaging if lasting over 6 weeks
PT
Presentation of osteomyelitis
Fever, restriction of movement and non-weight bearing
May be due to contiguous spread or due to trauma/surgery
Organisms od osteomyelitis
MC
Cat/dog bite
Sickle cell
Vertebra
Prosthetic
MC - S. Aureus
CAT/Dog - Pasturella
Sickle cell - salmonella
Vertebrae - TB\Prosthtic - S. epidermitis
Diagnosis for osteomyelitis
Bone aspiration - GOLD STANDARD
Demineralization, periosteal reaction, bone destruction (MRI showes before XR)
Elevated ESR/CRP
Blood culture
Management of osteomyelitis
Remove ALL hardware
IV ABX 4-6 weeks acute; 8+ weeks chronic
Diabetic ulcer likely for osteomyelitis
Over 2cmx2cm foot ulcer
Management of acute v chronic pain
Acute - determine if nociceptive or neuropathic
Chronic - Consult with regular provider
NSAID Ceiling effect for Naproxen, Diclofenac, and Ibuprofen
Naproxen: 500 mg (1000 mg/day)
Ibuprofen: 400 mg (1200 mg/day)
Diclofenac: 50 mg (150 mg/day)
NSAIDS in CKD
Not absolutely CI
Weight risk/benefit
4 Risk Factors for NSAID GI toxicity
History of a previously complicated ulcer
Age >65
High dose NSAID therapy
Concurrent use of aspirin/corticosteroids/anticoagulants
Use PPI
5 special pain management cases and tx
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
4 pearls of opioid use
Discuss goals of tx
Short, low dose course
Combine with NSAID or TYlenol
Oral preferred over IV
Presentation of septic arthritis
Single swollen warm and painful joint with fever and systemic symptoms
Knee and hip are MC places
3 common pathogens for septic arthritis
Staph Aureus in normal
Gonorrhea more common if sexually active
Pseudomonas in IVDU
Diagnosis of septic arthritis
50,000+ WBCs in joint aspirate
Or 1,000+ in prostetic joints
Management of septic arthritis (3 regimens for 3 microbes)
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
Medial epicondylitis
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
Lateral epicondylitis
Tennis elbow
Pain with wrist extension and forearm supination; tx: activity modification, counterforce bracing, PT, steroid injection, surgery for failed PT 4-6mo
Signs for carpal/ulnar tunnel syndromes
Phalen (only CT) and Tinnell (both)
Management of ulnar/carpel tunnel syndrome
NSAIDs
Splinting
Steroid injection
Decompression if severe
De Quervain’s Tenosynovitis
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
2 Thumb collateral ligament injuries
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
Dupuytren Contracture presentation
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)
Diagnosis and management of Dupuytren Contracture
Dx - Clinical;
Tx: injected collagenase or steroid, fasciotomy or fasciectomy if pt is refractory to 1st line therapy
Mallet Finger
(baseball – tear at DIP joint): avulsion of extensor tendon ⇒ forced flexion; can’t straighten distal finger
Management of mellet finger
XR = bony avulsion of the distal phalanx; tx: splint DIP uninterrupted extension x6 weeks or surgical pinning
Boutonniere deformity
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
Management of Boutonniere deformity
XR not required; tx: splint PIP in extension x4-6 weeks
Felon
Infection of the pulp space of the fingertip, usually with staphylococci and streptococci
Herpetic whitlow:
Herpes virus infection around the fingernail (thumb sucking)
Management of ganglion cyst
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)
AC joint separation
From FOOSH or direct shoulder trauma
Step up deformity and pain with cross chest testing
Eval and management for AC joint separation
XR with patient holding weight to assess severity
Sling and analgesia, surgery if more severe
Biceps tendonitis
Popey deformity
Pain at bicipital groove
NSAIDs, PT, steroid injection; surgical release for refractory cases
2 signs for biceps tendonitis
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
Imaging and Management for rotator cuff tear/ tendonopathy
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
Rotator cuff muscles with tests (3)
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
Special test and management for adhesive capsulitis
Apley scratch test; tx = NSAIDs, PT, steroid injection
3 tests for subacromial impingement
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
Management for subacromial impingement
XR may show a subacromial spur
Tx: rest, ice, activity modification, NSAIDs, steroid injection, arthroscopic surgery if refractory to conservative
Patellar tendonitis-Presentation
Activity-related, “jumper’s knee”, swelling over tendon and tenderness at the inferior border of the patella
Diagnosis of patellar tendonitis
XR may show inferior traction spur in chronic cases (enthesophyte), U/S = thickening tendon and hypoechoic areas; MRI shows tendon thickening;
Management of patellar tendonitis
Ice, rest, activity modification, PT; surgical excision and suture repair as needed;
Steroid injection = CI d/t risk of tendon rupture!!!!!
Presentation and management of ACL tear
Pop with knee giving out
Positive lachman’s test (most sensative)
MRI to confirm with PT and surgery for young active patients
MCL and LCL injury presentation and management
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
Mechanism and presentation of PCL tear
Blow to the knee while flexed or bend like landing hard during sports fall
Posterior drawer sign or sag sign
Management for PCL tear
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
Meniscal Tear
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
3 lateral ligaments of the ankle
anterior talofibular ligament (ATFL) - MC injury
calcaneofibular ligament (CFL), and
posterior talofibular ligament (PTFL)
Test for achilles tendon rupture
THompson test (calf squeeze)
Management of achilles tendon rupture
Surgical repair for early ROM, splint with the ankle in some plantar flexion
Plantar fasciitis
Presentation
Management
Tx
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
Tarsel Tunnel
Presentation
Sign
Dx
Tx
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
Bunion/Hallux Valgus
Presentation
Dx
Management
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
Morton neuroma
Sx
Dx
Tx
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
3 degrees of sprains
1 - Stretched but intact
2 - 1/3 to complete tear
3 - Complete rupture with avulsion potentially
Ice application for sprains and strains
10–15 minutes at a time, 3-4 times a day.
2 MC strain locations
Hamstring muscle and the lower back
3 degrees of strains
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
5 Hepatic Causes of RUQ pain
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
4 splenic causes of LUQ pain
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
Presenation and MC etiology of appendicitis
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
3 signs of appendicitis
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
Dx and Tx of appendicits
Imaging if atypical presentation - appy ultrasound or abdominal CT scan
CBC - neutrophilia supports the diagnosis
TX: surgical appendectomy
Definitions of cholelithiasis, cholangitis, cholecystitis, and choledocholithiasis?
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.
Presentation of cholelithiasis
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
Dx and Tx for cholelithiasis
RUQ ultrasound - high sensitivity and specificity if >2 mm. CT scan and MRI
TX: Asymptomatic—no treatment necessary
Elective cholecystectomy for recurrent bouts
Presentation of cholecystitis
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
Dx and management of cholecystitis
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
Dx for choledocholithiasis
ERCP = gold standard
Presentation of acute hepatitis
Recent travel with sudden jaundice, RUQ pain, scleral icterus, fever
HAV, Parasites, Alcohol can cause it
Diagnosis of acute hepatitis
Hepatomegaly and GB thickening on US
Hyperbilirubinemia with elevated AST and ALT
Liver enzyme suggestive of alcoholic hepatitis
AST:ALT>2
Anti-HBcIgM and HBsAG present
Acute HBV
HBSAg alone
Early HBV disease
Anti-HBcIgG and Anti-HBs
Resolve acute hepatitis
AntiHBs only
Vaccinated and resistant
AntiHBcIgG and HBsAg
Chronic HBV
Supportive care for Hepatitis
Fluids
Manage clotting issues
Manage encephalopathy
THiamine/Folate supplementation
Medical therapy for hepatitis
Entacavir for severe HBV
Pentoxifylline or steroids for severe alcoholic hepatitis
Diagnostics for pancreatitis
Abdominal CT is the diagnostic test of choice - required to differentiate from necrotic pancreatitis
ERCP is the most sensitive for chronic pancreatitis
GET SMASHHED causes of pancreatitis
Gallstones, Ethanol, Trauma, Steroids, Mumps, Autoimmune disease, Scorpion sting, Hypercalcemia, Hyperlipidemia, ERCP and Drugs.
Pancreatitis 5 Ransons criteria for poor prognosis at admission
Age > 55
Leukocyte: >16,000
Glucose: >200
LDH: >350
AST: >250
6 Ransons criteria at 48 hours
Arterial PO2: <60
HCO3: <20
Calcium: <8.0
BUN: Increase by 1.8+
Hematocrit: decrease by >10%
Fluid sequestration >6L
Presentation and management of anorectal abcess, or fistula
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
Presentation and management of anal fissure
Tearing rectal pain with bright red bleeding after
Superficial cut
Sitz bath - heals in 6 weeks
Botox if failing conservative tx
4 signs of appendicitis
- Periumbilical pain (intermittent and crampy) 2. Nausea/vomiting 3. Anorexia 4. Pain migrates to RLQ (constant and intense pain), usually in 24 hours
MC disease presenting with anorexia
Appendicitis
WEAPON mneumonic for gastric cancer
Weight loss, Emesis, Anorexia, Pain/epigastric discomfort, Obstruction, Nausea
6 Medications causing anorexia
sedatives, digoxin, laxatives, thiazide diuretics, narcotics, antibiotics
5 differentials to consider in constipation
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
Presetation of cholangitis with pentad and triad
Infection of billiary tract
Charcot’s triad - Pain, Fever, Jaundice
Reynauds pentad - Charcot + Altered mental status and hypotension
DIagnosis for cholangitis
US - Initial
ERCP - Best
Management of cholangitis
Cipro and Flagyl
ERCP to remove stones
Cholecystectomy post-acute
Primary sclerosing cholangitis
Jaundice and pruritus
Associated with IBD, cholangiocarcinoma, pancreatic cancer, colorectal cancer
Budd-CHiari syndrome
Hepatic vein thrombosis
Triad of abdominal pain, ascites, and hepatomegaly
Presentation of hepatic encephalopathy
Ammonia accumulates and reaches the brain causing ↓ mental function, confusion, poor concentration
Asterixis (flapping tremor) - have patient flex hands
Dysarthria, delirium, and coma
Presentation of esophageal vein rupture
Dilated submucosal veins, retching or dyspepsia, hypovolemia, hypotension, and tachycardia
Medical management of ascites
Salt restriction and diuretics (furosemide and spironolactone)
Paracentesis if tense ascites, SOB, or early satiety
Definition of constipation (Rome criteria)
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
One must consider differential for constipation over 50
Colorectal cancer
Workup and management for constipation
CHeck for opioid use
CBC, CMP, TSH
Increase fiber
Laxatives Metamucil (Bulk forming)>Polyethylene glycol (Osmotic)>Stimulant/Suppository/Stool softeners
4 pathogens to suspect in daycare diarrhea
Rotavirus, Cryptosporidium, Giardia, Shigella
Cruise ship diarrhea
Norovirus
Picnic/Egg salad diarrhea
Staph aureus
Seafood diarrhea
Cholera (rice water stools), V. Parahemolyticus
Raw ground beef or seed sprouts diarrhea
Salmonella
Home canning diarrhea
C. perfringens
C Botulinum
HIV diarrhea
Cryptosporidium
Presentation of diverticulitis
Left sided appendicitis
Fever/chills/Nausea/vomiting/left-sided abdominal pain
Dx of diverticulitis
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
Management of diverticulitis
Pain control and liquid diet
May us abx
Metamucil and HIgh fiber diet to prevent
2 Medications that can cause esophagitis
NSAIDs or Bisphosphonates
Management of esophageal candidiasis
Fluconazole 100 mg PO Daily
HSV v CMV esophagitis and managment
HSV - Punch lesions use acyclovir
CMV - Large solitary ulcers use gancyclovir
Management of corrosive esophagitis
Steroid
Management of eosinophilic esophagitis
Allergen elimination
Steroid topical of inhaled
Prevention of bisphosphonate indiced esophagitis
Take with water avoid reclining for 30-45 minutes
General presentation of gastritis
Dyspepsia (belching, bloating, distension, and heartburn) and abdominal pain are common indicators of gastritis
DIagnosis, Location and management of H. Pylori gastritis
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
Dividing line for upper/lower GI bleeds
Ligament of trietz
6 potntial causes of an upper GI bleed
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
Management of upper GI bleeds
NPO
Fluids
Oxygen
IV PPI until cause determined
Blood transfusion thresholds
Under 9 in high risk pts (ie. elderly, CAD)
Under 7 in everybody else
6 causes of lower GI bleeds
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
Presentations, DIagnosis and Management of GIardiasis
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
Presentation, management, and diagnosis of enterobiasis
Pinworm
Perianal pruritis worse at night
Peds
Scotch tape test with egg visualization under microscopy
TX with mebendazole or pyrantel pamoate
Presentation, management and diagnosis of Taeniasis (Tapeworm)
GI sx and weight loss
B12 defdiciency with hx of undercooked meat consumption
Tape test for D. latum, stool for eggs
Tx: Praziquantel
Presentation, diagnosis and management for hookworm
Cough, weight loss, anemia, recent travel, anemia
Hx of serpigionous rash (foot to lungs to GI)
Stool for adult worms
TX: mebendazole or pyrantel
Presentation, diagnosis, and management of roundworm
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
Presentation, diagnosis, and management of amebiasis
Bloody diarrhea and tenesmus, liver abcess,
Stool for trophozooites
Iodoquinol or paromomycin
Flagyl for liver abscess
Presentation, diagnosis and management of schistosomiasis
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
Diagnosis and management for heartburn
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
Zollinger Ellison syndrome
Gastrin secreting tumor - resect and PPI
Presentation of GI and esophageal cancer
Esophagus - Progressive dysphagia to solids with weight loss, hematemesis
GI - Abdominal pain and unexplained weight loss, Dyspepsia, N/V, early satiety
Presentation, diagnosis and management of external hemorrhoids
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)
Presentation and management of internal hemorrhoids
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
WHen to refer an umbilical hernia to surgery
WHen it continues beyond two years
Direct v Indirect inguinal hernia
Indirect through the internal inguinal canal - may enter scrotum, more likely to than direct
Direct through external canal at hesselbach’s triangle
3 types of hernia entrapments
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
Presentation, diagnosis, and management of Ulcerative COlitis
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
Presentation, diagnosis, and management of crohn’s disease
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
Presentation, diagnosis and management of toxic megacolon
Septic and febrile with abdominal pain
Distended colon, more common with UC than Crohns
Decompression and potential colon resection
Presentation of ischemic bowel disease and MC site
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
DIagnosis of bowel ischemia
Mesenteric angiography is considered the gold standard
Abdominal X-ray shows “thumb-printing” of small bowel or right colon due to submucosal bleeding
Management of bowel ischemia
Supportive: Bowel rest, fluids, antibiotics
Laparotomy with bowel resection for bowel infarction
Revascularization is the gold standard
First Sign of Jaundice
Scleral icterus
Serum billirubin of jaundice
Serum bilirubin > 2.5 mg/dl
Prehepatic Jaundice
Hemolytic
Increased indirect/unconjugated bilirubin, mild hyperbilirubinemia
Dark urine due to hemoglobinuria; dark stool
Intrahepatic Jaundice
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
Posthepatic jaundice
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)
Presentation, diagnosis and management of a mallory weiss tear
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
6 Potential causes of melena
Gastric cancer,
Duodenal ulcers,
Right-sided colon cancer,
Portal hypertension with esophageal varices,
Severe erosive esophagitis,
Mallory-Weiss syndrome.
7 potential causes for hematochezia
Hemorrhoids,
Anal fissures,
Polyps,
Proctitis,
Rectal ulcers, and
Colorectal cancer.
Diverticulosis is generally an incidental finding since diverticular bleeding is usually of greater volume
Eight potential causes of nausea
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
Management of nausea
Standard nausea meds:
Scopolamine patch,
Dexamethasone (4mg),
Ondansetron (4mg)
Rescue anti nausea:
Prochlorperazine,
Droperidol
GI cocktail (3 ingredient) and test of nausea in ED
Maalox, viscous lidocaine, droperidol
PO challenge in ED – eat something before going home ⇒ can be performed with GI cocktail
MCC of small bowel obstruction
Postoperative adhesions - adults
Intussussception - Peds
Presentation of SBO
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
Diagnosis of SBO
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
Management of SBO
Treat with decompression with an NGT, surgery if a mechanical obstruction is suspected
MCC and setting of Large Bowel Obstruction
Cancer - COlon or rectum
Presentation of LBO
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
Diagnosis of LBO
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
Management of LBO
Bowel rest, NG tube placement, surgery as directed by the underlying cause
Vomiting and bowel obstruction
More common in SBO
Pain in bowel obstruction
SBO - Shorter and more frequent cramps
LBO - Longer and less frequent cramps
Duodenal vs. Gastric ulcer - how to tell the difference
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
Diagnosis of PUD
Upper endoscopy with ulcer biopsy for H pylori and neoplasia
Management of PUD
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.
MCC and presentation of bronchiolitis
RSV = MCC
Wintermonths
Infants and young children
Tachypnea, respiratory distress, wheezing
Dx of bronchiolitis
DX: Nasal washing for RSV culture and antigen assay; CXR = normal
Management of bronchiolitis
Most effective/only therapy
5 indications for hospitalization
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
Presentation of acute bronchitis
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
MC agents of acute bronchitis
Most common - viral (95%)
Common bacterial = M. catarrhalis
Chronic lung patients: H. influenzae, S. pneumoniae, M. catarrhalis
Diagnosis of acute bronchitis
DX: Obtain CXR if the diagnosis is uncertain or symptoms persist despite conservative treatment
Management of acute bronchitis
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
Presentation of epiglottitis
Haemophilus influenzae type B (Hib)
Usually in unvaccinated children
Tripod with dysphagia, drooling, and respiratory distress
Diagnosis of epiglottitis
Thumbprint sign on Lateral XR
Culture for H. flu
CT scan shows narrow airway
Definitive = laryngoscopy with cherry red epiglottis
Management of epiglottitis
Intubation, supportive care
Rocephin
May treat outpatient if stable
MOA of ARDS
⇑ 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
Presentation of ARDS
Rapid onset of profound dyspnea occurring 12-24 hours after the precipitating event
Tachypnea, pink frothy sputum, crackles
Diagnosis of ARDS
CXR shows air bronchogram and bilateral fluffy infiltrate
Management of ARDS
PaO2 and SAO2 goals
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
Diagnosis of asthma
REVERSIBILITY!!
Spirometry with pre and post-therapy (albuterol inhalation) readings
Decreased FEV1/FVC (75-80%)
> 10% increase of FEV1 with bronchodilator therapy
Acute asthma treatment - 4 things
Oxygen,
Nebulized SABA (albuterol, etc.)
Ipratropium bromide, and
Oral steroids
Presentation and MCC of croup
Infection of the upper airway, which obstructs breathing and causes a characteristic barking cough and stridor
Caused by the parainfluenza virus
Diagnosis of croup
Steeple sign on CXR
Management of croup
Supportive (air humidifier), antipyretics
Severe: IV fluids and nebulized racemic epinephrine, steroids
Presentation of FB aspiration
Inspiratory stridor (high) or wheezing (low)
Elevated temp and pulse, some decreased breath sounds (lobar)
Choking/Gagging
Hx of institutionalization, sedation, alcohol
Dx of FB aspiration
Mediastinal shift and hyperinflation shown on CXR - may also see FB
ABG to assess ventilation
More common location for foreign body inhalation
Right main stem bronchus over left
Management of FB inhalation
Treatment: Remove foreign body with a bronchoscope
Rigid bronchoscopy is preferred in children, while flexible is diagnostic and therapeutic in adults
3 MCC of hemoptysis
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
Diagnostics for hemomptysis patients
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
Management of hemoptysis
ABC’s
DIagnosis and Management of influenza
Rapid antigen test to dx
BIlateral diffuse infiltrates on CXR
Zanamivir or Oseltamivir within 48 hours of symptoms
Antivirals reduce illness by 1 day
Presentation of Small cell lung cancer
15% of lung cancer cases with 99% being smokers
Recurrent pneumonia with anorexia, weight loss, and weakness
Associated s/s of small cell lung cancer
Superior vena cava syndrome
Laryngeal nerve palsy
Horner syndrome
Malignant pleural effusion
Digital clubbing
Eaton lambert syndrome
Eaton lambert syndrome
MC in SCLC
Similar to myasthenia gravis (proximal muscle weakness/fatigue, diminished DTRs, paresthesias (lower extremity)
Diagnostics of SCLC
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
Management and prognosis for SCLC
Combination chemotherapy with 10-13% survival rate
CANNOT be treated with surgery
3 types of NSCLC
Squamous cell 25-35%
Large cell - 5%
Adenocarcinoma - 35-40%
Presentation of squamous cell carcinoma
Central
May cause hemoptysis
Hypercalcemia with elevated PTH
Presentation of large cell lung cancer
Rapid growth with response to surgery
60% are peripheral
Gynecomastia
Presentation of lung adenocarcinoma
Peripheral - associated with smoking and asbestos
Peripheral with thrombophlebitis
Management for NSCLC
Stage 1-2 surgery
Stage 3 Chemo then surgery
Stage 4 palliative
Management of a pulmonary nodule
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
Presentation of pertussis
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
Diagnosis and management of pertussis
Nasopharyngeal swab
Treat with a macrolide (gram negative) and b2 agonsit
Presentation of pleural effusion
Presents with dyspnea and a vague discomfort or sharp pain that worsens during inspiration
Lights criteria for pleural effusion
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
Transudative Causes Vs. Exudative Causes
Trans - Hydrostatic pressure, liver, etc.
Ex - Infection, cancer
Dx of pleural effusion
Lateral decubitus XR
Thoracocentesis = gold standard to treat
PLeurodesis for recurrent or drains
4 causes of pleuritic chest pain and definition
Characterized by sudden and intensely sharp, stabbing, or burning pain in the chest when inhaling and exhaling
Pneumonia
Pericarditis
Pericardial effusion
Pancreatitis
Causes of viral pneumonia in kids and adults
Kids - RSV
Adults - Flu
Presentation, dx, and management of bacterial pneumonia
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
Coccidiodmycosis
Non-remitting cough/bronchitis non-responsive to conventional tx
Fungal inhalation in western states; test with EIA for IgM and IgG
Tx: fluconazole / itraconazole
Pulmonary aspergillosis
Usually those with healthy immune systems
Tx: fluconazole / itraconazole
Cryptococcus
Found in soil; can disseminate and à meningitis
Lumbar puncture for meningitis
Tx: amphotericin B
Histoplasmosis
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
CD4 threshold for pneumocystis jirovecci
Under 200
Diagnosis and management for pneumocystis jirovechi pneumonia
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
CURB-65 scoring
Confusion,
Urea >7,
RR >30,
Systolic BP < 90 mmHg or Diastolic BP ≤ 60 mmHg,
Age >65
CURB-65 interpretation
0-1 = low risk, consider home tx
2 = probable admission vs close outpatient management
3-5 admission, manage as severe
General presentation of a pneumothorax
Acute onset ipsilateral chest pain and dyspnea with decreased tactile fremitus, deviated trachea, hyperresonance, diminished breath sounds
Diagnosis for pneumothorax
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
Management of small pneumothorax
Under 15%
Will resolve spontaneously
Management of large pneumothorax
Chest tube placement
Management of tension pneumothorax
Large bore needle decompression
Management for all pneumothoraces
CXR every 24 hours until resolved
EKG of a PE
TACHYCARDIA (most common),
S1Q3T3 (rare),
Non-specific ST wave changes
Initial and definitive diagnostics for PE
And 2 CXR signs
Spiral CT - Initial
Pulmonary angiography - Definitive
CXR: Westermark sign or Hampton hump (triangular or rounded pleural base infiltrate adjacent to hilum)
Management of a PE
Heparin followed by DOAC
3 MCC of SOB
COPD
Asthma
CHF
DIagnosis for SOB - 6 s/s
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
Management for SOB - 6 pearls
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
> 5 mm positive tuberculin testers
At high risk, fibrotic changes on CXR, immunocompromised HIV/drugs, steroids/TNF antagonists daily, or close contact with pt with infectious TB
> 10 mm positive tuberculin testers
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
> 15 mm positive tubercuulin testers
Everyone
Sputum smears for TB
Need 3 negative AFB smears to be considered negative
BBiopsy shows caseating granulomas
Management of latent TB - 3 regimens
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)
Rifapentine-Moxy therapy for TB
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)
Quad therapy (RIPE) for TB
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”
Management of altered mental status
Naloxone is opiate OD suspected
ABC’s
Thiamine and dextrose
GCS Eye scores
Eye-opening:
4- spontaneous
3- voice
2-pain
1-none
GCS Verbal scores
Verbal:
5-oriented
4-confused
3-inappropriate words
2-incomprehensible
1-none
GCS Movement scores
- Motor:
6-obeys commands
5-localizes pain
4-withdraws
3-abnormal flexion (decorticate)
2-abnormal extension (decerebrate)
1-none
GCS threshold for intubation
8 or less
3 pathologies of paresthesia with worup
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
Presentation of Bell’s palsy
Unilateral facial nerve paralysis with no other findings
Peak in 48 hours with viral prodrome
NOT FORHEAD SPARING
Keratitis from inability to close eyes
Management and of Bell’s Palsy
Treatment is prednisone, artificial tears, tape eyelid shut
Comments: Bilateral: Lyme disease, infectious mononucleosis
Presentation of encephalitis
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
Diagnosis of encephalitis
lumbar puncture and MRI
PCR for viruses
Kernig’s and Brudzinski’s usually absent
Management of encephalitis
Supportive care and acyclovir 10 mg/kg IV q8hr started promptly
Empiric antibiotics are often given until bacterial meningitis is excluded
Presentation of status epilepticus (2 potential criteria)
> or equal to 5 min continuous seizure activity or more than one seizure without recovery from the postictal state in between episodes
Management of status epilepticus
Place in left lateral decubitus position
Benzo - 1st line
Phenytoin - 2nd line
Phenobarbitol or lacosamide - 3rd line
Watch for resolution of acidosis post
Management for focal seizures
Phenytoin or Carbamazepime
May or may not loose consciousness (simple v. complex)
EEG and Management of absence seizures
EEG ⇒ brief 3-Hz, spike, and wave discharge
Tx: ethosuximide
8 other types of seizures
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
Presentation of epidural hematoma
Transient loss of consciousness following injury
LUCID with headache and one sided weakness
MC - Middle meningeal artery bleed
Diagnosis and management of an epidural hematoma
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)
Presentation of a subdural hematoma
Head injury followed by neurological symptoms - often seen in the elderly or in alcoholics with hx of falls
Dx and management of subdural hematoma
Non-contrast CT scan showing crescent shaped bleed
Observe if small
Surgery ⇒ burr hole trephination, craniotomy, craniectomy
ANterior cord syndrome
Loss of pain/temperature below the level of the lesion preserved joint position/vibration
Central cord syndrome
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)
Cord transection syndrome
Rostral zone of spared sensory levels (reduced sensation caudally, no sensation in levels below injury); urinary retention and bladder distension
Brown Sequard syndrome (cord hemisection
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
Presentation of Guillain-Barré syndrome
Ascending paralysis after immunization or infection (C. jejune, CMV, EBV)
Diagnosis and management of Guillain Barre
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
Presentation of concussion
Mild TBI with potential loss of consciousness less than 30 minutes
GCS 13-15
Amnesia, HA, Nausea, vomiting
Diagnosis of a concussion
Use validated clinical decision rules to determine if imaging is warranted - No routine imaging of pediatric patients with mTBI
Usually a clinical diagnosis
Gradual concussion return 6 steps
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
Most significant risk factor for stroke
HTN
Commoness of different stroke types
Ischemic: 85% - 2/3 thrombotic, 1/3 embolic
Hemorrhagic - 15%
Presentation of a stroke
Hemiparesis opposite of side of stroke, Hemisenory deficit,
Presentation of stroke in the Anterior circulation (anterior cerebral/middle cerebral arteries)
Associated with hemispheric s/s (aphasia, apraxia, hemiparesis, hemisensory loss, visual field defect)
Presentation of stroke in the posterior circulation (vertebral/basilar arteries):
Coma, drop attack, vertigo, n/v, ataxia
Presentation of stroke in the carotid/ophthalmic:
amaurosis fugax
Presentation of stroke in the MCA
Aphasia, neglect, hemiparesis, gaze preference, homonymous hemianopsia
Presentation of stroke in the ACA
Leg paresis, hemiplegia, urinary incontinence
Presentation of stroke in the PCA
Homonymous hemianopsia
Presentation of stroke in the basilar
Coma, cranial nerve palsies, apnea, drop attack, vertigo
Presentation of stroke in the lacunar
Silent, pure motor or sensory
Diagnosis of a stroke
Non-contrast CT
Transcranial doppler US, echo for ischemic stroke
Management of a stroke
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
Ischemic stroke BP control
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
12 Exclusion criteria for stroke tPA
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
Presentation, diagnosis and management of a cluster HA
Excruciating periorbital pain, lateral/temporal
Ptosis, miosis, lacrimation, conjunctival injection, rhinorrhea, nasal congestion
Occur in clusters
100% oxygen, sumatriptan (prophylaxis: CCBs)
Presentation and management of migraine headaches
Nausea, photo/phonophobia, aura
Pulsating HA
Abortive tx – triptans, Dihydroergotamine (DHE), antiemetics, NSAIDs
Prophylaxis – beta-blockers, CCBs, TCAs
Presentation of Subarachnoid hemorrhage
Worst HA of my life with potential sudden LOC
Ruptured berry (saccular) aneurysm accounts for 75% nontraumatic
Diagnosis and management of a subarachnoid hemorrhage
non-contrast head CT, LP (elevated opening pressure / grossly blood fluid in all 4 tubes
May do cerebral angiography
Management of SAH and berry aneurisms
Manage BP
Surgical clipping/wrapping of the aneurysm
Anticonvulsants for seizure prevention
Presentation, Diagnosis and Management of an intracerebral hemorrhage
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
Brain aneurysms DX/TX
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
6 Syncope red flags
Syncope during exertion,
Multiple recurrences in short time,
Heart murmur,
Old age,
Significant injury during syncope,
Family history sudden unexpected death
5 DDX’s for ataxia
Drugs (ETOH) and toxins
Tumors
CVAs
Genetics
B12 deficiency
Presentation of a TIA
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
Diagnosis for a TIA
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%
Management of a TIA
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
Causes of delerium, dementia, and amnesia
Dementia (Alzheimer’s)
Delirium (withdrawal or infection)
Amnesia (head injury, CVA, etc.)
Reversible and irreversible causes of dementia
Irreversible causes: vascular dementia, Creutzfeldt-Jakob
Reversible: depression, B12 deficiency, syphilis, hypothyroidism, NPH, drug use, intracranial mass
Management of dementia
Tx: cholinesterase inhibitors (donepezil); NMDA antagonists (memantine) à don’t cure, just slow progression
Presentation and management of BPPV
Positional, no hearing loss, tinnitus, ataxia, dx: Dix-Hallpike test; tx: Epley maneuvers, meclizine
Management of vestibular neuritis
Not positional, no hearing loss/tinnitus, tx: meclizine
Presentation and management of labrynthitis
Acute, self-resolving episode; vertigo, hearing loss tinnitus, tx: meclizine + steroids
Presentation and management of meneirre’s disease
Chronic, relapsing, remitting; vertigo + hearing loss + tinnitus; tx: diuretics, salt restriction, CN VIII ablation for severe cases
Presentation and management of perilymphatic fistula
A history of trauma; vertigo from trauma; tx: fix damage surgically
Presentation and managment of Acoustic neuroma
Ataxia, neurofibromatosis type II, MRI findings: vertigo, hearing loss, tinnitus, and ataxia; tx = surgery
Classic Triad of meningitis and presentation
fever > 38 C,
nuchal rigidity (stiff neck),
headache
NO AMS
Causitive agents of meningitis
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
Diagnosis of meningitis
LP AFTER checking for increased intercranial pressure via CT scan (papilledema is clue for increased ICP)
Management of meningitis
Aseptic: symptomatic or IV acyclovir for HSV
Bacterial: dexamethasone + empiric IV antibiotics (cephalosporin, Vanco, penicillins)
Household contacts: treat with rifampin, Cipro, Levaquin, azithromycin, ceftriaxone
