EOR Topics to Review Flashcards
What are contraindications to using thrombolytics for stroke treatment?
- TCP < 100,000
- Active bleed
- GI ulcer or bleeding within the last 3 weeks
- Ischemic stroke or MI within the last 3 months
- Known bleeding disorder
- Major surgery (intracranial or intraspinal) within the last 3 months
- History of ischemic stroke
- INR > 1.7, PT > 15 s, aPTT > 40 s while on ACT
- Evidence of hemorrhage on imaging
- SBP must be < 185, DBP must be < 110
Description of subdural vs epidural hematoma on imaging
Epidural: lens/lemon shaped hyperdensity, does NOT cross suture lines
Subdural: crescent shaped hyperdensity, CAN cross suture lines
What is a situation in which you should start empiric therapy for meningitis before doing the lumbar puncture?
Always start empiric therapy after performing a lumbar puncture UNLESS the pt is showing signs of ICP and warrants a head CT –> waiting to start abx post CT delays care too long
What are clinical signs of ICP?
Papilledema (swelling of optic disc on fundoscopic exam)
AMS
Lethargy
Seizures
HA
Peds: high pitched cry, bulging fontanelle
What signals ICP on imaging?
Mass effect (cerebral shifting to one side)
MOI for anterior cord, central cord, and Brown Sequard injuries
Anterior: flexion or ischemia
Central: hyperextension
Brown Sequard: penetrative trauma
Clinical manifestations of spinal cord injuries
Anterior: loss of sensation, pain/temp and motor ability below injury/lesion level, preserved proprioception and vibration
Central: sensory and motor deficits in UE > LE
Brown Sequard: ipsilateral loss of motor, vibration and proprioception at the level of the injury with contralateral loss of pain and temp 2-3 levels below the lesion
MG versus LE pathophys
MG = autoimmune destruction of postsynaptic membrane ACh receptors (WORSE with movement)
LE = destruction of presynaptic membrane ACh receptors (BETTER with movement)
C4/C5 radiculopathy (C5 root) manifestations
Pain - medial scapula, lateral upper arm
Weakness - deltoid, supra/infraspinatus
Sensory loss - lateral upper arm
Reflex loss - brachioradialis, “supinator” reflex
C5/C6 radiculopathy (C6 root) manifestations
musculocutaneous n. involvement
Pain - lateral forearm, thumb, index finger
Weakness - biceps, brachioradialis, wrist extensors
Sensory loss - lateral forearm and thumb
Reflex loss - biceps reflex
C6/C7 radiculopathy (C7 root) manifestations
Pain - medial scapula, posterior arm, dorsum of forearm, third finger
Weakness - triceps, wrist flexors, finger extensors
Sensory loss - posterior forearm, middle finger
Reflex loss - triceps reflex
C7/T1 radiculopathy (C8 root) manifestations
Pain - shoulder, ulnar side of forearm, fifth finger
Weakness - thumb flexors, abductors, intrinsic hand muscles
Sensory loss - fifth finger
Reflex loss - N/A
First line gout treatments
Acute management:
NSAIDs (naproxen, indomethacin) + ice
Colchicine (CI if severe kidney disease)
Steroids (PO or IV prednisone depending on severity, caution in pts with DM)
Chronic management:
Allopurinol
Probenecid (uricosuric, helps increase renal excretion of uric acid)
Kanavel criteria for flexor tenosynovitis
1) Tenderness along the course of the flexor tendon
2) Fusiform or symmetrical swelling of the finger
3) Pain with passive extension
4) Flexed posture of the finger
Flexor tenosynovitis treatment
IV abx (vanco and broad spectrum penicillins)
Olecranon bursitis vs septic arthritis of elbow
Olecranon bursitis – localized swelling of olecranon bursa, not associated with nearly as much erythema, systemic signs of infection or warmth to palpation –> DOES NOT REQUIRE JOINT TAP, treat with NSAIDs
Septic arthritis – swelling, warmth, fever, tenderness to palpation, SIRSy –> REQUIRES JOINT TAP, traet with abx
Muscle sprain treatment of choice
NSAIDs + rest
What physical exam finding is consistent with supraspinatus tendonitis?
Hawkins-Kennedy test – assess impingement
Jobes (empty can) test – best assesses supraspinatus function in isolation
Physical exam findings of AC joint separation versus anterior shoulder dislocation
Anterior shoulder dislocation – loss of rounded aspect of shoulder, externally rotated and slightly abducted, prominent acromion
AC joint separation – tenderness to palpation over AC joint
Which murmur is most associated with rheumatic heart disease/fever?
Mitral stenosis
Describe the findings of mitral stenosis
Mid diastolic, rumbling murmur with an opening snap
How can you distinguish afib with RVR versus SVT on EKG?
Afib with RVR = irregular rhythm
SVT = regular rhythm
First line pharmaceutical mgmt for SVT vs afib with RVR
SVT = adenosine 6 mg IV
Afib with RVR = metoprolol or diltiazem IV (get rate control)
Are murmurs that occur after S2 diastolic or systolic?
Diastolic
Aortic regurg description
Soft, high pitched blowing diastolic murmur best heard at LUSB in 3rd intercostal space, louder/better auscultated when pt is sitting up and leaning forward
What is the #1 risk factor for aortic dissection?
HTN
Aortic regurg most common presentation
Dyspnea, pulmonary edema (bibasilar rales)
What is the BP med of choice in pts with aortic dissection and hypertension?
Esmolol (goal is SBP < 120)
First line antihypertensives in hypertensive emerency for pts with:
- Eclampsia
- Hypertensive encephalopathy
- Pulmonary edema
- Aortic dissection
Eclampsia = magnesium sulfate +/- labetalol, hydralazine
Hypertensive encephalopathy = nicardipine
Pulmonary edema = vasodilators FIRST (nitroglycerin, sodium nitroprusside), can f/u with diuretics after
Aortic dissection = esmolol
What historical factors point more towards cardiogenic etiologies of syncope?
Absence of pre/postdromal symptoms
Syncope with exertion
Murmur on physical exam
Treatment for acute decompensated heart failure
LMNOP
L: lasix (or another diuretic if contraindicated)
M: morphine
N: nitroglycerin drip
O: oxygen if O2 sat < 92% (non rebreather, noninvasive positive pressure ventilation)
P: position head of bed to 30 degrees
NSTEMI/STEMI treatment
Acute mgmt: MOAN + DAPT + anticoagulate + reperfuse
MOAN = morphine for irretractable pain, oxygen if O2 < 92%, aspirin 325 mg crushed, nitroglycerine
DAPT = aspirin + tocagrelor prior to PCI, continue indefinitely (can use clopidogrel in pts with true aspirin allergy)
Anticoagulate = eliquis, xarelto
Reperfusion = PCI
Discharge/long term mgmt: BASH + continuation of DAPT
BASH = beta blocker, ace inhibitor, statin, and heparin
When do you initiate transcutaneous pacing and/or atropine for AV blocks?
If patient is hemodynamically unstable
What is the appropriate chronic treatment for Mobitz II or 3rd degree AV block?
Permanent pacemaker (can admit for observation in asymptomatic Mobitz II patients)
What is the most common cause of acute arterial occlusion?
Thrombus/atrial fibrillation
Hallmarks of thyroid storm
Tachycardia, hyperthermia, hypertension, exophthalmos
6 D’s of dilated cardiomyopathy etiology
Dunno (idiopathic)
Drugs (cocaine, antivirals such as HIV meds)
Disease (viral infection)
Doxorubicin
Deficiency (B12)
Drinking alcohol
V fib treatment algorithm
Early defibrillation + CPR (queue up 1 mg epi IV while machine is getting ready) –> can administer epi q3-5 min
Which of the following is most consistent with reflex syncope/vasovagal response?
A) Absence of a postdrome
B) Postevent confusion
C) Prodrome with dizziness
D) Provocation with prolonged standing
D
A – c/w cardiogenic syncope
B – c/w seizure
C – c/w cardiogenic syncope or seizure
What are the 2 big stroke mimics?
Hypoglycemia –> ALWAYS GET A POC GLUCOSE IN SUSPECTED STROKE
Aortic dissection –> check distal pulses and BP in both arms
Multifocal atrial tachycardia treatment
Supportive care
+/- oxygenation
Characteristics of LBBB on EKG
W in V1, M in V6, large wide R wave in lead I
pSVT management algorithm
If HDS: Valsalva –> adenosine 6 mg IV –> adenosine 12 mg IV –> cardiovert
If hemodynamically unstable: start with cardioversion
Acute angle closure glaucoma treatment
PO or IV acetazolamide (carbonic anhydrase inhibitor, decreases aqueous humor production), topical timolol or another beta blocker, topical apraclonidine (alpha agonist) + immediate ophtho consult for potential iridotomy
Consider mannitol if refractory to initial medical management
MC pulmonary complication of influenza
Pneumonia secondary to superimposed bacterial infection (MRSA, strep pneumo MC)
Anterior vs posterior epistaxis
Anterior (MC, often seen in kids) = comes from the kiesselbach plexus, less severe bleeding, treat with direct pressure, topical vasoconstrictors (i.e. Afrin aka ozymetazoline), silver nitrate cautery, packing and d/c with orders to follow up for packing removal in 24-48 hours
Posterior = comes from the sphenopalantine artery, report bleeding from b/l nostrils, treat with packing (balloon or foley nasal catheter)
What meds should be avoided in R sided MI?
Vasodilators (i.e. nitro) b/c patients are preload dependent
R sided MI treatment
IV fluids (fluid resuscitation helps avoid hypotension)
Spinal epidural abscess big 5
Etiology: common in immunocompromised (DM) pts, pts with alcohol use disorder or misuse of IV drugs
S/sx: low back pain, fever, loss of bladder/bowel function+/- presence of focal neurologic deficits
Dx: emergent MRI of lumbar spine
Tx: emergent NSGY consultation for drainage and decompression + broad spectrum abx
What calcium level warrants dialysis?
> 18 mg/dL
Cholangitis vs acute hepatitis
Cholangitis = RUQ pain, jaundice, fever, AMS, hypotension (Reynold’s pentad or Charcot’s triad), markedly elevated ALP
Acute hepatitis = history of alcohol use, AST:ALT is 2:1, tender hepatomegaly!!!
Painful versus painless vision loss
PAINFUL = optic neuritis, GCA, acute angle closure glaucoma
PAINLESS = central retinal artery or vein occlusion, retinal detachment
Patellar dislocation treatment
Closed reduction + follow up XR to r/o fractures, then knee immobilization and rest with orthopedic follow up
Respiratory distress treatment algorithm
Start with nasal cannula 6 L –> venturi mask –> nonrebreather –> high flow nasal cannula –> noninvasvie positive pressure ventilation –> endotracheal intubation
What meds provide mortality benefit in ACS?
BASH + DAPT + anticoagulants + beta blockers + statins
Treatment of stroke 2/2 sickle cell in kids
Exchange transfusion (tPA not indicated in kids)
Is bowel/bladder retention or incontinence more specific for cauda equina?
Retention – incontinence only develops later in disease as a result of overflow
Which is more sensitive for cauda equina – bowel/bladder retention or saddle anesthesia?
Bowel/bladder retention
ADRs of ace inhibitors
Cough
Hyperuricemia/hyperkalemia
Angioedema
Dose 1 hypotension
ADR of amiodarone
Pulmonary toxicity with chronic use – lead to pulmonary fibrosis
ADR of heparin
Thombocytopenia leading to bleeding and microthrombi formation (tx of HIT = d/c heparin, start a direct thrombin inhibitor i.e. dabigatraban)
ADR of metoprolol
Hypotension, erectile dysfunction, lightheadedness
ADRs of tPA
Hemorrhage/bleeding, anaphylaxis/allergic reaction/angioedema
Top 2 diagnoses for flank pain
Nephrolithiasis
AAA –> get a CT AP with contrast!
Which is more reliable for ruling out testicular torsion: presence of Prehn or cremasteric reflex?
Presence of cremasteric reflex
What structure is most commonly injured in ski accidents?
Ulnar collateral ligament d/t forced radial abduction
Skier thumb presentation and treatment
TTP on ulnar side of MCP joint, weak pincer grasp
Thumb spica splint, ortho referral
MC location of mesenteric ischemia
Superior mesenteric artery (d/t emboli, uncoagulated afib = high risk), jejunum most affected
Myocarditis diagnostic tool gold standard
Myocardial biopsy (though rarely performed, often a clinical diagnosis – echo can show hypokinesis and decreased ventricular ejection fraction)
Protein and LDH ratios in transudative vs exudative pleural effusion
Transudative = low protein ( < 0.5) , low LDH ( < 0.6) with respect to the pleural fluid
Exudative = high protein ( > 0.5), high LDH ( > 0.6) with respect to the pleural fluid
*** ratio is pleural serum:fluid
What kind of events are most likely to cause PTSD?
Sexual trauma
Treatment for asymptomatic first degree AV block
Reassurance, no intervention necessary
When should you start with ordering a D dimer for suspected DVT?
If suspicion is low/moderate after doing Wells and you are unable to PERC them out, b/c a negative D dimer will r/o DVT without any imaging
What tests are required to make a diagnosis of pyelonephritis?
Only a UA, (+) for WBCs, leuks, nitrates if E. coli is causative organism (non con CT AP would help look for potential obstruction but not inflammation associated with pyelo)
What are drusen spots associated with?
Macular degeneration
Classic physical exam finding a/w PCP toxicity + treatment?
Rotary nystagmus (like a diagonal nystagmus) + feeling of superhuman strength, combative
Treatment = benzodiazepines
1st line gout treatment in pts with kidney disease
Prednisone (colchicine and NSAIDs CI in CKD)
Hematuria work up
MCC of hematuria: UTI, trauma, stone
Initial workup: UA, full H&P, assess kidney function with Cr
If initial workup does not yield cause: renal US or CT AP w/ contrast to look for structural disease or mass (now have concern for malignancy)
Renal ADR of chronic lithium toxicity
Nephrogenic DI d/t arginine vasopressin resistance
Interstitial nephritis
Kidney failure
What is the specific finding on echo for cardiac tamponade?
Diastolic collapse of RV
Risk factors for depression mnemonic
SADPERSONS
Sex (MC in M than F)
Age (increased risk in M > 45 y/o) and adolescents)
Depression
Previous attempt
Ethanol or drug use
Rational thinking loss
Social supports lacking
Organized plan
No spouse
Sickness (mental health disorder or general medical issue)
What are the 8 PERC criteria?
Age greater than or equal to 50
History of PE or DVT
Recent surgery or trauma
Taking oral contraceptives
Unilateral leg swelling
HR greater than or equal to 100
O2 sat < 95% on RA
Hemoptysis
Pharmacologic treatment of Meniere’s
Thiazide diuretics (and salt restriction)
What is a felon and what is the best treatment?
Felon = pyogenic infection of digital subQ tissue usually d/t staph aureus (gram positive cocci in clusters)
Tx = I&D + antibiotics if overlying cellulitis present
Which form of vaginitis has a pH < 4.5?
Candidiasis
Ottawa ankle rules
Get an ankle XR if:
- Unable to bear weight for more than 4 steps
- Bony tenderness at medial or lateral malleolus
- Bony tenderness in mid foot
Get a foot XR if:
Pain in midfoot PLUS…
- Navicular tenderness
- Pain at base of fifth metatarsal
- Unable to bear weight
Saturday night palsy nerve involvement + presentation
Radial nerve damage
S/sx: weakness of brachioradialis, wrist drop (manifestation of weak wrist extensors), weakness of finger extensors
Distinguishing tension pneumo and pericardial effusion/tamponade on physical exam
Tamponade: JVD, hypotension, decreased CARDIAC sounds on auscultation (bilateral), breath sounds usually present
Tension pneumo: JVD, hypotension, decreased BREATH sounds on auscultation (unilateral to side of injury)
Where do you perform decompression in a pneumothorax?
2nd ICS in midclavicular line OR 4th/5th ICS in anterior axillary line
Treatment of stable vs unstable sinus bradycardia
Stable = observation
Unstable = start with atropine, consider epi/norepi if unresponsive, consider transcutaneous pacing
TTP manifestations and best treatment
FATRN: fever, anemia (likely d/t hemolysis), thrombocytopenia, renal dysfunction, neurologic deficits/dysfunction
Treatment: plasmapharesis to address both anemia and TCP (avoid platelet transfusion if possible bc additional platelets will be destroyed given microvascular circulation)
PDA treatment
Indomethacin within first 10-14 days of life
Umbilical prolapse presentation and treatment
Fetal heart decels, pulsating mass protruding from cervical os
Tx: immediate/emergent C section, elevate presenting part (maternal knee to chest positioning, Trendelenburg) in time prior to delivery
MC valve involved in endocarditis leading to embolic events?
Tricuspid (mitral regularly)
Treatment of choice for lice?
Permethrin (ok in pregnant, lactating women, kids)
Strangulated hernia presentation and treatment
Mass near or in scrotum, toxic appearing, s/sx of SBO (N/V – bilious, abdominal pain, hyperactive BS early on to absent BS later on)
Alcohol related hepatitis tx
Supportive care
Which bursa does the knee joint communicate with?
Suprapatellar – this is why you can “milk” knee joint effusions
What finding indicates pneumothorax on CXR?
Ability to see pleural edge indicating buildup of air in pleural space
What is Nikolsky sign?
Sliding of epidermis away from underlying dermis
Which has a negative Nikolsky sign, bullous pemphigoid or pemphigus vulgaris?
Bullous pemphigoid (THINK: this is BULL, NO way I have a Nikolsky sign)
How can you tell if acidosis/alkalosis is acute vs acute on chronic?
Acute = no signs of compensation
Acute on chronic = signs of compensation (i.e. ROME is present but the other respiratory/metabolic process is also abnormal in an effort to compensate)
Which of the MOAN meds in MOAN and BASH for ACS has a proven mortality benefit?
Aspirin
What are the 2 instances where you DONT do a CT AP with contrast?
If pt has CKD, if solely looking for nephrolithiasis
Treatment of corneal ulcer
Topical ciprofloxacin (for contact wearers)
Causative agent of bronchiolitis and presentation
Pathogen = RSV
Pres = SOB, viral prodrome (cough, runny nose, fussiness), accessory muscle use on PE, wheezing, UNRESPONSIVE to nebulizer treatment
Paraphimosis vs phimosis
Para = worse, unable to replace foreskin distally back to its anatomic position
Phimosis = unable to expose glans penis b/c cant retract foreskin proximally
Erysipelas presentation
Abrupt onset of erythema and swelling of the skin + infectious symptoms (fever, chills)
Often follows a malar distribution but will not have systemic symptoms like Lupus, infectious sx + no acne like lesions help differentiate from rosacea
Erysipelas treatment
Amoxicillin or cephalexin (inf often caused by strep pyogenes)
Pertussis treatment
Azithromycin (1st line), or bactrim (if PCN allergic)
What kind of event has the highest likelihood of causing PTSD?
Sexual violence
Volvulus presentation, dx, and tx
Pres = insidious onset/slowly progressive abdominal pain, chronic constipation
Dx = xray shows (+) bent inner tube sign for sigmoid volvulus, which shows colonic dilation pointing to the LUQ, (+) bird’s beak on contrast enema
Tx = flexible sigmoidoscopy to reduce volvulus followed by surg to reduce recurrence
What is volvulus
Redundant loop of sigmoid colon twists and obstructs the lumen
MC chest injury in children with severe blunt trauma
Pulmonary contusion
At what point do you administer D5W when treating DKA?
When glucose becomes < 200
When do you stop DKA treatment?
When anion gap is closed
DKA treatment mainstay
1st = IV fluids!!!
Then = potassium repletion FOLLOWED BY insulin drip, eventually need to transition to SQ insulin before d/c IV insulin
What pathogen causes abscesses to form?
MRSA
what antibiotics do we use to treat purulent/more severe cellulitis?
Clindamycin – has MRSA coverage (can also do bactrim, doxy)
Osteopenia and osteoporosis T scores
Osteopenia: -1.5 to -2.5
Osteoporosis: less than -2.5
Parotitis treatment
Outpatient: clindamycin or augmentin
Inpatient: IV unasyn (amp-sulbactam) or a cephalosporin + metronidazole – indications for admission include fever, which shows severe disease that wont respond to PO treatment
What is a SLAP tear and how does it present?
Superior labrum anterior posterior tear
Pres = baseball player with history of shoulder/glenohumeral issues, hears clicking and popping while throwing, pain at its worst while in the cocked position getting ready to throw
CAP outpatient treatment
F’ing MAD
Fluoroquinolones (prolong QT, tendonitis – not used as often d/t ADRs)
Macrolides – azithromycin (atypical coverage)
Amoxicillin – good gram positive cvg
Doxycycline – gram pos, good gram neg, and atypical coverage
What is the JAK2 mutation responsible for?
Primarty polycythemia vera, causes increased RBC production
XR showing dilated loops of bowel with air fluid levels indicates what?
SBO
How do you DEFINITIVELY diagnose Meniere’s?
Post mortem dx
In real-life – exclude other causes of vertigo with an MRI, audiometry to confirm SNHL, etc.
Meniere’s presentation = episodic vertigo, HL, tinnitus
Tx = lifestyle mods (decreased salt intake), thiazide diuretics, vestibular rehab, etc.
Meniere’s likely etiology
Excess of endolymph
What vascular structure is most likely to be damaged with tibiofemoral (knee) dislocation?
Popliteal artery
Which physical exam finding indicates popliteal artery damage and warrants urgent ortho f/u?
A) ABI of 0.95
B) Asymmetric distal pulses
C) Dusky skin of involved extremity
D) Significant hemarthrosis
C – this indicates compromised popliteal artery flow
A – ABI < 0.9 is when you start to get worried about arterial disease
B – warrants urgent arteriogram to determine likelihood of arterial damage
D – primary finding of knee dislocation
Risk factors for bone fracture
- Low BMI
- Osteoporosis (MC in older F patients)
- Untreated hyperthyroidism
- Glucocorticoid therapy (d/t increased bone resorption)
- Current cigarette smoking
T or F: OA is a protective factor against bone fractures
True
Orbital blowout fracture presentation
Diplopia
Pain with EOM d/t inferior rectus entrapment
Enophthalmos (globe sunken into orbit)
Limited upward gaze
Decreased sensation to cheek, upper lip, and/or gingiva (d/t infraorbital nerve damage)
+/- intractable vomiting 2/2 pain
MOI of orbital blowout fractures
Direct force to the globe by small round object (ball, fist, etc.)
Orbital blowout fracture dx and treatment
Dx: CT – (+) teardrop sign, aka herniated tissue and muscle
Tx: surgery, cold packs and oral steroids to decrease swelling while waiting, +/- antiemetics, prophylactic abx if fracture extends into the sinuses
Hep B active infection (HBsAg positive) PEP for healthcare workers
With UTD hep B vaccines: none
With unknown or out of date hep B vaccines: one dose of hep B vaccine and one dose of hep B immunoglobulin
If contact is HBsAg negative: one dose of hepatitis B vaccine only
How do you CONFIRM hyperaldosteronism?
Oral sodium loading test – 2 weeks of high sodium diet and removing certain meds followed by drawing plasma renin activity or a direct renin assay
DIAGNOSTIC = plasma renin activity < 0.65 OR direct renin assay < 0.36
Pres: young person with refractory hypertension, hypokalemia and elevated bicarb on labs
Presentation of DKA vs HHS
DKA: more likely to have ABDOMINAL PAIN, Kussmaul respirations, weakness, neurologic symptoms in moderate to severe cases, signs of dehydration – tachycardia, dry mucus membranes, orthostatic hypotension, decreased skin turgor, fruity breath odor
HHS: focal neurologic deficits much more common (d/t higher glucose), obtundation/stupor/coma
Etiology of central DI versus nephrogenic DI
Central = decreased ADH secretion
Nephrogenic = decreased sensitivity to ADH
Best test to distinguish central versus nephrogenic DI
Water deprivation and ADH administration
Water deprivation test results for nephrogenic vs central DI
Central DI = exogenous ADH stimulation causes an increase in bodily H20 uptake, urine becomes more concentrated and osmolality INCREASES as a result
Nephrogenic DI = exogenous ADH administration does nothing b/c kidneys are unable to respond, urine osmolality UNCHANGED
What does urine osmolality measure?
The amount of DISSOLVED PARTICLES
high osmolality = lots of dissolved particles = little water = highly concentrated
low osmolality = few dissolved particles = lots of water = low concentration
Which of the following requires empiric antibiotic therapy?
A) Clostridium perfringens
B) Salmonella
C) Shiga-toxin-producing E. coli
D) Shigella
Shigella (with quinolones, macrolides, or beta lactams)
Post partum hemorrhage presentation and treatment
Etiology = 4 T’s (tone – uterine atony, trauma, tissue – retained palcenta, thrombin – coagulation)
Pres = boggy uterus!!!, hypotension, tachycardia, pallor, hypothermia, and LOC
Tx = uterine massage, bimanual compression if atony is suspected, oxytocin infusion, tranexamic acid if bleeding continues, intrauterine balloon catheter if atony and hemorrhage persist after tranexamic acid, final option = hysterectomy
Hepatic encephalopathy and hepatic insufficiency health maintenance (pharmacologic)?
Encourage probiotic use (i.e. lactobacillus) – helps with ammonia elimination
Preferred method of imaging potential nephrolithiasis in pregnant patients
Renal ultrasound
What is a Bankart lesion?
Avulsion of glenoid labrum from inferior glenoid, often occurs with anterior shoulder dislocations
Direct vs indirect inguinal hernia
Direct = goes through defective abdominal wall (Hesselbach triangle) and passes directly through the external ring, medial to the IEA. does not descend into the scrotum
Indirect = more common, goes through internal ring and passes lateral to the IEA. DOES descend into the scrotum , higher risk of strangulation
THINK: MDs dont lie –> Medial to IEA = direct, Lateral to IEA = indirect
Treatment for nonreducible hernias
emergent surgery consultation
Ectopic pregnancy hCG levels
Serum hCG ~3600 (hCG of 900 non detectable on TVUS, c/w absence of IUP)
TVUS finding c/w incomplete miscarriage
Endometrial thickening (occurs b/c there was initial implantation)
Placental abruption risk factors
Previous abruption (biggest RF)
HTN
Cocaine
Trauma
Multiparity
Smoking
Placental abruption presentation
PAINFUL vaginal bleeding (+/- bleeding visualization, can be internal)
Contractions
Abdominal tenderness
Decreased fetal movement
Placental abruption diagnostics and tx
TVUS – want to avoid doing a bimanual on suspected abruption d/t risk of hemorrhage
Tx: hospital admit for C section +/- hysterectomy if bleeding cannot be controlled
MCC of cardiac tamponade?
Malignancy
Osteomyelitis empiric abx in a fracture
Type 1 or type 2 fracture – cefazolin (for gram positive coverage)
Type 3 fracture – cefoxitin or cefotetan (additional gram negative coverage)
Add vanco if MRSA risk
Best test for diagnosing pancreatic insufficiency?
Fecal elastase – will show decreased levels which is c/w chronic pancreatitis causing pancreatic insufficiency
Complications of sinusitis
Brain abscess in frontal lobe (vs temporal lobe c/w mastoiditis)
Treatment of choice for unequivocal disc herniation and pts with muscular weakness?
Discectomy with limited laminotomy
Classic SBO findings on imaging
Abdominal XR: dilated loops of bowel, air fluid levels, string of pearls
Abdominal CT (BEST imagining modality): pneumoperitoneum – appears as air under the diaphragm and indicates rupture
SBO management
Initially: volume resuscitation d/t vomiting, correct electrolyte abnormalities, bowel rest, GI decompression with NG tube
If no improvement over 3-5 days –> surgical management/correction
Balanitis treatment
Uncomplicated: clotrimazole
Complicated or severe s/sx (intense pruritus or pain): fluconazole
Currant jelly sputum
Klebsiella (gram negative rod)
Foul smelling sputum
Fusobacterium nucleatum
Strep pneumo sputum appearance
Blood tinged
Peak flow parameters for asthma exacerbations
Mild: 25-39%
Moderate: 40-69%
Severe: > 70%
diagnostic tool of choice when working up a pt < 45 y/o w new cardiac symptoms
TEE
Best method to prevent osteomyelitis after a fracture?
A) Administer IV abx
B) High pressure irrigation with antibiotic solution
C) Obtain wound cultures in ED
D) Perform surgical stabilization within 6 hours of injury
A
B – want to do LOW pressure, high volume to avoid pushing debris further into the wound
C – not helpful in determining antibiotic choice
D – not shown to lower complications
How do you treat mycoplasma pneumoniae?
Same as CAP
Fing MAD for outpt
Fing BAD for in pt or immunocompromised out pt
What physical exam finding is most sensitive for acute compartment syndrome?
Pain is most sensitive
(pallor and pulselessness are rare)
What medication is the best treatment for bulimia?
Fluoxetine
What joint is involved in the motion responsible for ankle sprain?
Subtalar
Cystic fibrosis increases the risk of what respiratory infection
Pseudomonal pneumonia
How do you treat CAP in a patient with cystic fibrosis?
Zosyn (pip tazo) and ciprofloxacin
What diseases put patients at increased risk of developing tenosynovitis?
DM, RA, deposition disorders (i.e. sarcoidosis)
What is trigger finger?
Stenosing flexor tenosynovitis causing the finger to be locked in flexion
How do you treat hydronephrosis accompanied with palpable bladder and new onset kidney failure/disease?
Bladder catheterization
How do you treat hydronephrosis in the setting of an intrinsic cause such as PKD or a renal mass?
First try ureteral stent placement, percutaneous nephrostomy if that fails
Cough description in pertussis
Develops after a cold
Present throughout the day and night but worsens in the evening
Asthma exacerbation treatment (4 things)
O2
Duo-neb (albuterol, SABA + ipratropium, ICS)
Magnesium (vasodilator)
Best test to CONFIRM diagnosis of TB?
NAAT – only way to confirm TB, others are more sensitive but less specific
How often do you do DEXA scanning if the T score is normal?
Every 10 years
Every 3 years if T score is -1.5 to -1.99, every 1-2 years if being treated for low bone density
Which risk factor is the most important to decrease to lower risk of developing ACS?
Atherosclerotic plaque level – get LDLs under control with a statin
Treatment of purulent vs non purulent cellulitis
Purulent = clindamycin (or bactrim, doxy)
Non purulent = cephalexin or dicloxacillin (cover staph and strep)
DKA lab findings
Acidic blood pH on VBG/ABG
Pseudo hyperkalemia
Pseudo hyponatremia d/t elevated glucose
Decreased serum bicarb
Release of NO and endothelin from subarachnoid blood clots causes what?
Vasospasm
Brown recluse spider bite appearance
Red plaque that has dusky red eschar
Best initial diagnostic study for peptic ulcer disease
Upright CXR
Bicuspid aortic valve causes what kind of murmur?
Aortic stenosis
Presentation of aortic stenosis
Syncope
Angina
Dyspnea
THINK: SAD
Electrolyte abnormalities with SIADH
Hyponatremia
Serum hypo-osmolality
Urine hyperosmolality (> 100)
Elevated oligoclonal bands on LP
Multiple sclerosis
MCA stroke manifestations
Contralateral weakness of face, arm, leg
Contralateral sensory impairment
Aphasia, dysarthria
Hemineglect on nondominant side
Infective endocarditis prophylaxis treatment of choice in pts with cardiac hsitory (cardiac transplant, rheumatic heart disease, etc.) penicillin alg
Azithro (first choice is amoxicillin if non PCN allergic)
Priapism tx
Low flow (ischemic): venous, painful, emergency – treat with corpus cavernosa aspiration and intracavernous phenylephrine
High flow (non-ischemic): arterial, semierect, painless – treat with observation or arterial embolization
Mid dilated pupil should make you think what?
Acute angle closure glaucoma
How long does a manic episode have to last to make a diagnosis of bipolar I?
One week
Risk factors for developing tamponade other than malignancy
SLE
Infectious processes (viral, bacterial, TB)
Post MI
What vessels are damaged in:
- Epidural hematoma
- Subdural hematoma
- Subarachnoid hemorrhage
- Intracerebral hemorrhage
- Epidural: middle meningeal artery
- Subdural: bridging veins
- Subarachnoid: ruptured berry aneurysm MCC
- Intracerebral: penetrator arteries
Disease that is a risk factor for subarachnoid hemorrhage
Polycystic kidney disease (younger patients, + fam hx, palpable kidneys, multiple cysts noted on renal US/CT)
EKG findings of a R sided MI
ST elevations in V3R and V4R
(Clinical manifestations: Kussmaul breathing, JDV, signs of R sided HF)
Which is better at detecting vegetations, TEE or TTE?
TEE
Which endocrine disorder is pretibial edema associated with?
Thyroid storm/hyperthyroidism
Treatment of choice for fungal infections of the scalp?
Selenium sulfide shampoo
Ranson criteria usage
Predicts mortality in cases of acute pancreatitis
Ranson criteria components
at admission:
- age > 55
- WBC > 16
- Glucose > 200
- LDH > 350
- AST > 250
48 hours after admission:
- hematocrit falls > 10%
- BUN rises > 5
- Calcium < 8
- PaO2 < 60
- Base deficit > 4
- Fluid sequestration > 6
Each criteria is worth one point, score of 0-2 = 1% mortality, 3-4 = 15%, 5-6 = 40%, >7 = 100%
Top 3 MCC of acute pancreatitis
- Gallstones
- Alcohol
- Hypertriglyceridemia
Giardia transmission
Fecal oral transmission by ingesting cysts in contaminated water
Giardia presentation
Abrupt onset of colicky abdominal pain, pale, loose/foul smelling stools, explosive diarrhea
Giardia treatment
Metronidazole 250 mg TID x7 days
What kind of GI infections is cipro good to treat?
Bacterial
Rifaximin is first line treatment for…
Traveler’s diarrhea and hepatic encephalopathy
Acute and chronic hypocalcemia treatment
Acute: IV calcium gluconate
Chronic: oral calcium and vit D supplements
What is Murphy’s sign specific to?
Cholecystitis (inspiratory arrest with palpation of RUQ)
COPD exacerbation mgmt
Anticholinergics (ipratropium)
SABA (albuterol)
Steroids (prednisone)
Noninvasive positive pressure ventilation (indicated if acidotic, hypercapnic, hypoxic, or resp fatigue)
Abx if signs of bacterial inf or if ventilation is required
Thyroid storm treatment
Adrenergic blockade with propranolol FIRST, then PTU (pref) or methimazole and steroids
Red flags of back pain (require imaging for further workup)
Back pain plus…
- Fever (c/f abscess)
- Acute onset (c/f fracture)
- Unintentional weight loss (c/f malignancy)
- Morning stiffness > 30 min in young adult (c/f spondyloarthropathy)
- Urinary/bowel retention or incontinence, saddle anesthesia (c/f cauda equina)
- Coagulopathy
- Immunocompromised
- Recent surgical instrumentation
Bullous pemphigoid big 5
Etiology: autoimmune
S/sx: large, tense blisters or bullae
Dx: clinical, negtive Nikolsky sign
Tx: steroids, doxy, +/- immunosuppression
Erythema infectiosum is caused by
Parvovirus B19
What should you be concerned about if a patient is hypotensive and has renal colic?
Early AAA
MC respiratory infection in patients < 2 y/o
Bronchiolitis (caused by RSV)
Physical exam findings concerning for mesenteric ischemia
Diffuse abdominal pain out of proportion to physical exam findings – eventually progresses to signs of peritonitis
Which area of the bowel is most likely to have ischemic changes?
Jejunum b/c it has least collateral blood flow from the SMA (most likely area to clot)
Epiglottitis big 5
Etiology: Hib
Pres: tripod, drooling, wheezing, increased work of breathing
Dx: Lateral CXR shows thumbprint sign
Tx: close airway monitoring, ENT and anesthesia c/s, IV vanco and 3rd gen cephalosporin after securing airway
Myocarditis presentation
Excessive fatigue, exercise intolerance
Chest pain
Unexplained sinus tach
S3, S4 gallop
Abnormal EKG
Elevated troponin
Pertussis treatment
Azithro or bactrim if macrolides are CI (avoid bactrim in pts with G6PD b/c it causes hemolysis)
Mastitis tx
Out pt: dicloxacillin or cephalexin
In pt: vanco
Hyphema vs subconjunctival hemorrhage
Hyphema = blood in anterior chamber, infiltrates iris
Subconjunctival hemorrhage = blood in sclera ONLY, does not infiltrate iris
Ultrasound findings for ovarian torsion
MC = ovarian enlargement
90% of the time = whirlpool sign
What hormone can help slow vaginal bleeding?
Estrogen pills
Characteristics of R versus L atrial enlargement on EKG
R atrial enlargement: peaked P waves in lead II, large positive P wave deflection in lead V1
L atrial enlargement: widened P waves in lead II, large negative P wave deflection in lead V1
Risk factors for rhabdo
PROLONGED IMMOBILIZATION!!!
Intense exercise leading to muscle breakdown
What type of fractures should sugar tong splits be used to immobilize?
Elbow, wrist, forearm
Short arm gutter splint use
Immobilize wrist and ulnar or radial half of hand
What is the first step to consider in all burn patients?
Tetanus prophylaxis
Hyperkalemia EKG changes
- Peaked T waves
- Prolonged PR interval
- Prolonged QRS duration (widened)
Aspiration PNA treatment
Augmentin or Unasyn (ampicillin-sulbactam) for anaerobic coverage
Pertussis treatment of choice
Azithro (or bactrim in pts intolerant to macrolides)
Antibiotics of choice in COPD exacerbation
Only give abx in moderate to severe exacerbations (worsening of at least 2 cardinal sx – cough, dyspnea, sputum production)
Azithro (macrolides) or doxy
At what O2 sat or PaO2 do you give prednisone in pts with PJP?
O2 sat < 93%
Pa O2 < 70
Acute mesenteric ischemia presentation and dx
Acute onset of poorly localized, severe abdominal pain and vomiting out of proportion to physical exam findings
Dx: elevated serum lactate, CT angiography MC test but mesenteric angiography is gold standard
Giardia transmission and treatment
Transmission: common in daycare, also contaminated water
Tx: tinidazole 2 g PO for one dose
Epiglottitis causative agent
Haemophilus influenza type B (HIB)
Antitussives that can be used in acute bronchitis?
Dextromethorphan
What is the timeline for which tamiflu is effective?
Given within 48 hours of symptom onset (after that just supportive care – oral rehydration and rest)
Crohn vs UC
Crohn: gum to bum involvement, skip lesions, but more common in small intestine. More common to have manifestations outside of GI tract and to develop fistulas d/t transmucosal involvement
UC: submucosal involvement, continuous ulcerations in the rectum that extend proximally. More likely to develop malignancy
What GI condition is dermatitis herpetiformis (pruritic vesicobullous lesions on elbows, knees and buttocks) consistent with?
Celiac
Otitis externa causative organisms, pres and treatment
Organism: pseduomonas (MC) or staph
Pres: erythema of external auditory canal, tragal tenderness with manipulation, HL
Tx: otic ciprofloxacin or ofloxacin with topical steroids (hydrocortisone, dexamethasone)
Peritonsillar abscess treatment
Needle drainage (do NOT have to wait for ENT to do it unless this is the first time)
Treatment of choice for chemical burns to the eye (acidic or alkaline)
Numbing with topical tetracaine anesthetic drops, then begin irrigation
Treatment for corneal abrasions
Contact wearers – Ciprofloxacin ophthalmic solution (want to cover pseudomonas)
Non-contact wearers – erythromycin
What is Reye syndrome
Encephalopathy and hepatic issues in the setting of NSAID use after a viral illness
Treat with supportive care
Does COPD paint more of a respiratory alkalosis or respiratory acidosis
Respiratory acidosis bc it is an OBSTRUCTIVE lung disease so even in its most tachypneic state, Co2 cannot be properly excreted which means CO2 retention leads to acidosis
Balanitis tx
Mild = topical clotrimazole (covering candida, MC organism)
Severe = oral fluconazole
3 types of incontinence:
Overflow (think obstructive causes like BPH – c/o difficulty starting stream, incomplete emptying)
Urge (think stroke, Alzheimer’s – c/o urgency and frequency)
Stress (think pregnancy, history of urologic procedures – c/o small volumes of urine loss with coughing or sneezing)
MCC of SJS/TEN
Drugs: PEC SLAPP
Penicillins
Ethosuximide
Carbamazepine
Sulfa drugs
Lamotrigine
Allopurinol
Phenobarbital
Phenytoin
If not drugs: mycoplasma pneumoniae infection
Atopic derm vs psoriasis location
Atopic derm = flexor surfaces
Psoriasis = extensor surfaces
Deficits in ulnar nerve and median nerve distribution corresponds to a lesion where?
T1 nerve root (makes up the medial cord, of which the median nerve and ulnar nerve come off of)
Mnemonic for encapsulated organisms iso sepsis w/ asplenia
SHNEKSS
Strep pneumo
H influenza
Neisseria meningiditis
E coli
Klebsiella
Strep (group B)
Salmonella typhi
EKG findings for PE
S1Q3T3 or sinus tachycardia (more commonly)
Heparin (prolongs PTT) and warfarin reversal agents (very prolonged PT)
Heparin = protamine sulfate
Warfarin = oral vitamin K for INR > 4 but asx patient, four factor prothrombin complex in HDUS pts
