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ER 1 Flashcards

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1
Q

Exudative Tonsillitis differentials and labs/ findings

A

Strep - rapid strep and culture
Mono- mono spot after day ten
Tonsillar abscess
Ludwigs Angina- trismus? Hot potato voice?
GC Chlamydia - when strep isn’t responsive to beta-lactam +doesn’t cause Mono rash

Cervical rom? Kernigs
Oriented?

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2
Q

Meningitis test?

A

Kernigs ( leg rotation) and brudzinski (neck)

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3
Q

What happens when you give Beta-lactam’s to mono?

A

Full body rash. But at least you know what you’ve got!

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4
Q

Otitis media with no abx in 3 mo dose

A

Amox 500 TID

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5
Q

Trauma labs and imaging

A

Chest x-ray always
CT head and neck almost always
X-ray anything else that hurts
Abdominal tenderness, you have to do labs: CBC CMP

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6
Q

Cellulitis,with pus. IV and po empiric abx

A

IV vanco 15 mg/kg + Cefepime 2g + flatly 500 my

PO Bactrim DS 1tab bid or TID or Doxy 100 mg BID

Redman syndrome w/vanco. Don’t mix Vanco with Zosyn it’s nephrotoxic

Do a ct scan with contrast to look for pus

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7
Q

Cellulitis, no pus, No wound

RX?

A

Group a strep
Keflex 500 mg four times per day PO

Clindamycin 300 mg 4x / day PO
600mg IV

Cefazolin 1 gram IV

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8
Q

Trismus

A

Lock-Jaw - can’t open mouth

Classically associated with TETANUS but also seen in Meningitis, Brain / Parotid / Dental / Facial Abscesses.

Most Commonly caused by infection/inflammation of the gums around the bottom 3rd (last) molar, especially if it never fully erupts, failing to separate from the the back of the jaw.

TMJ - Temporomandibular Joint dysfunction can also cause the masticator muscles to spasm causing trismus in the absence of infection.

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9
Q

LUDWIG’S ANGINA: what is it? Sxs? Rx?

A

LUDWIDGS IS CONSIDERED A THROAT ABSCESS

Cellulitis of the floor of the mouth, usually d/t dental infection.

Airway Risk - this is a 911 - BiLateral Submandibular Lymphadenopathy can close off the trachea

Its BILATERAL

Rx:
Airway!!! Intubate ASAP if threatened as it can close up quickly.

Treat for Streps w/ Penn G 2.4 million Units/day divided q/4 hrs in 600,000 unit IM injections into Gluteus Maximus (only give Penn G via deep IM)

and

Also treat for Anaerobes with Metronidazole: 1 gram IV to load then 500mg q 6hrs

Penn G 600,000 units IM 6X/day
+
Metronidazole 1 gram IV to load then 500mg q 6 hrs thereafter

Clindamycin if Penn Allergic

  • Admit to ICU
  • Consult ENT ASAP!!!!
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10
Q

RETROPHARYNGEAL ABSCESS

A

Infection of the post pharyngeal space.

AIRWAY RISK, but tricky as intubation may rupture it - if you can, get a CT before airway is even near compromised.

-Hot Potato Voice
-Under 3s
-Difficulty swallowing
-Prefers supine as sitting presses abscess into airway
making breathing more difficult.

RX:

Airway and humidified O2
Penn G IM + Metronidazole IV
Clindamycin if Penn Allergy

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11
Q

Penicillin Alternate if Allergy

A

Clindamycin, a Lincosamide antibiotic

Both kill mainly Gram + Aerobes but Clinda also kills
Gram (-) Anaerobic Rods.

That’s why it causes C.Dif in the gut. It kills off the gram negative anaerobes but leaves C.Dif, a gram positive Anaerobe.

Clinda is great for skin infections as it covers both strep and staph, even some MRSAs are still sensitive but resistance is increasing.

Psudomonas, HFlu, Legionella, Klebsiella… these guys are already all resistant Gram (-) rods but the the gut flora are still sensitive.

Good for Toxic Shock - which is usually a straight up staph infection gone septic.

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12
Q

Pilonidal Cyst Pathogen

A

BACTERIODES - Gram (-) Anaerobes.

Give Flagyl if you culture it and have ONLY anaerobes.

If there is a mixed infection of aerobes and anaerobes, you’ll have to add something to the Metronidazole or, just Augmentin as it covered G+ aerobes, even those that secrete betalactamase, AND it has excellent anaerobic coverage. Beware C. Dif though - It doesn’t kill G+ Anaerobes…. Really, only oral Vanco kills C. Dif off once you have an overgrowth.

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13
Q

midline depression above bow of lips is the…

A

Philtrum

Easy to confuse with frenum….:

Frenum or Frenulum refers to any fold of tissue that secures a mobile part of the body.

Frenum (labial) is the bit of skin that sometimes anchors the upper lip to the upper gum at anterior midline.

Frenum (Lingual) connects the tongue to the floor of the mouth

There are Frenula in the brain, the clitoris, on the penile foreskin…

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14
Q

Nasal Bone vs Nasal Spine

A

the Nasal Bone protruded from the Glabella (between eyes).

The Nasal Spine protrudes from the Maxilla (upper jaw) and is a sharp little midline point covered by the Piltrum above the lip.

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15
Q

As for BV and Candida

A

Affirm

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16
Q

Gardnerella fx

A

Flagyl 500 b.i.d. times seven

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17
Q

10 to 25,000 E. coli or staphylococcus?,

A

Contaminant level, over 75,000 or hundred with symptoms, treat it

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18
Q

Clue cells on a slide?

A

Bv, which is gardnerella

Fx is flatly 500 bid x 7 days ok in pregnancy

Also fishy

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19
Q

Why is Aza through myosin reasonable alternative for viral URI’s I know I said it was reasonable alternative I’m going to explain it

A

While it’s not an antiviral, it does have anti-inflammatory properties and thereby may decrease the patient’s perception of sis

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20
Q

Foamy green dish water discharge what is it?

A

Trick, flagellated, Fragile but three times a day and you have to treat the male partner maybe asymptomatic

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21
Q

Kleihauer Berle test

A

Aka fetal hemoglobin stain

Order when pregnant women suffer trauma, to detect has had contact with him

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22
Q

Do batik

A

Ach

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23
Q

PE probability scale

A

PeRC. W EL L score

With a negative the D- Dimer a well score of zero or if you can, PErC her out, you will have documented Low probability of PE

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24
Q

Menstruating female presents w and pain, tests?

A 
Serum preg
Cbc
Cmp 
Lipase
Crp

After seeing pt:

25
Q

Pecarn

A

PEDs algorithm for ct head scan after trauma

26
Q

, dose range for Toradol

A

30 to 60 mg Based on weigh

Other name is Ketorulac

27
Q

Effusion

A

M

28
Q

Standard low dose pain reliever IV

A

4 mg morphine for milligrams Zofran

If you want stronger, give 1 mg of the dilator with 4 mg

29
Q

Croup?

A

Used to because by diphtheria now mainly viral a dental virus RSV

Need to sort it from epiglottitis steeple sign on the x-ray

30
Q

Metabolic syndrome parameters

A 
HDL under 45
Triglycerides over 180
Waist circumference over 102 cm for men 88 cm for women, or thereabouts
Blood pressure 130/85 or greater
Fasting glucose of at least 110

LDL level is not a metabolic syndrome parameter

31
Q

Test for ruptured Achilles tendon?

A

Thompson

Squeeze gastrinemius. Should cause plantar flexion, impaired in our absence equals partial or full Achilles’ tendon tear

32
Q

ED work up for gross hematuria?

A

UA
CBC CMP
Sono if you think it’s a kidney
CT urogram shows thickening and urine flow

Antibiotic choice is levoquin

33
Q

Advair

A

Fluticasone with Salmeterol (a B2 agonist- long acting

For asthma or COPD exacerbation

34
Q

Metochlopramide

A

Re glam

35
Q

Nephrotic Syndrome

A

A Glomerular Pathology presenting with:

  • SWELLING, waking up with periorbital and bilateral peripheral swelling, sometimes ascites, especially in Children
  • Dizziness/Postural Hypotension

The direct cause is Hypo-Albuminemia. The blood is not thick enough to draw fluid in from the tissues, so fluid third spaces.

Hyperalbuinemia (below 3.5g/dL) can be a problem with the LIVER not producing or the KIDNEY, not filtering albumin out of the urine.

If LIVER is the cause - your patient ought to have signs of liver failure, cirrhosis or chronic hepatitis, which is itself caused by holes in the glomerulus which is itself caused by a number of bad things:
- N/V/Anorexia = portal backup
Ascities
-Jaund/Ictaris/Itchy Skin
-Palmar Erythema (not specific)
So go ahead and order LFTs and a CMP, a full panel of LFTs and Lipase

If KIDNEYS are the cause, your patient really ought to have albumin in the urine. Do a UA first thing when you see EDEMA, this will help narrow it from Liver to Kidney (unless both are on the fritz, in which case your patient will likely appear very ill indeed!)

If you’ve got high protein in the urine on a dip AND facial/peripheral edema (admittedly, asceites is more in the liver camp), look to your actual lab urinalysis to tell you is it albumin or myoglobin (Rhabdo? Trauma??). If its albumin go ahead and add a lipid panel to your blood tests (you’ve already ordered a CBC and CMP… right?
Because if its the kidneys that are leaking protein, the liver is going to be working overtime to replace them, this will lead to fats excess lipids in the blood as the liver will also overproduce lipoproteins.

If you have proteinuria, edema AND hyperlipidemia, especially in a kid - Just give him Prednisone IV AND an ACE (to drop pressure on the nephrons) while you continue tracking the cause, which is MOST LIKELY AUTOIMMUNE… Don’t knock yourself out trying to ID the actual cause as YOU’LL NEED A KIDNEY BIOPSY TO DO IT and most of the treatments are the same. So refer to Urology or better to Nephrology and put the patient on Pred and and ACE.

-#1 Cause is Minimal Change Disease (MCD)
is the MOST common cause of
Nephrotic Syndrome in kids
under 7 and, even in adults it’s a
good first bet. Pred + Ace is the
RX but Nephrology needs to be
consulted. You’ll need a
biopsy to ID Minimal Change.

   - In an adult, you've GOT to 
   consider cancer.  MULTIPLE
   MYELOMA to be specific.  Look
   for BENTZ JONES BODIES in 
   the urine.

-Lupus can do it too- order ESR, CRP and ANA. If any are (+) especially ANA, refer to Rheumatology.

36
Q

Nephritic vs Nephrotic Syndromes

A

Nephritic = Protein AND Blood in
in the urine with HypERtension

Neprhrotic = Only Protein in the
urine, also hyperlipidemia
and edema and HypOtension

Nephritic is the one associated with Strep (sore throat or cellulitis, even strep impetigo). The strep is no longer the problem though, its the IgA immune complexes created during the infection that are attacking the basement membrane.

Immediate Rx is the same for either: Prednisone and take the pressure off the neprhons with an ACE/ARB then refer to Urology/Nephrology. You’ll need a kidney biopsy to specifically ID the disorder.

37
Q

Tobramycin

A

Aminoglycoside Eye Drops

Very good against Pseudomonas

Oto toxic

After you remove a FB or ID a corneal abrasion, send patient home on Tobramycin or Erythromycin drops. Do NOT send them home with a bottle of tetracaine as they may KEEP it and use it next time instead of having the FB removed and end up with an ulceration

If the cornea has a stellate ulceration 1) refer to ophthalmology stat. This is herpes. Acyclovir is in this patient’s future but I don’t think we handle it.

38
Q

PORT Score

A

Pneumonia Severity Scale

Predicts Mortality Risk of Pneumonia

It isn’t supposed to direct admission vs outpatient rx for pneumonia diagnoses but we used it that way in the ED on borderline cases.

39
Q

PERC Criteria evaluate…

A

Risk of PE

It is used on LOW RISK patients only - to “Perk Them Out” of d-Dimer and CT Angiogram petting for PE.

If they’ve every had a clot anywhere or they’re on estrogen or recently air traveling or have a cast or are otherwise known to be hypercoaguable.. you MUST D-Dimer them and probably will also order the chest CTA at the same time.

40
Q

WELLS Criteria evaluates…

A

Risk of PE or DVT, clotting in general.

This is the better scale to use as you can use it on anyone.

WELLS SCORE over 4 - Image is required d/t HIGH risk of clotting.
Get Doppler for DVT if limbs seem to be involved. Get CTAngiogram of chest if oxygenation is impaired or chest pain on inspriation/expiration is involved

WELLS SCORE under 4= LOW risk of clotting. You can do D-Dimer blood test first before imaging.

41
Q

Gold Std Imaging for PE

A

CT Angiography

Do it of the chest for PE

Do it of the leg/limb for DVT

Spiral CT is great but doesn’t seem as available in practice as it seemed in school…

42
Q

Normal EtCO2 range

A

35 - 45 mmHg

10 means you have ROSC

If you have 0 EtCO2, you’ve intubated the stomach

43
Q

Parkland Formula calculates…

A

Fluid replacement for BURN patients

44
Q

Fluid Challenge

A

911 Fluid Resuscitation to rescue BP

2 20-gauge IVs antecubitally if poss, in the jugular if not. 2 -4 L of 0.9% NS delivered as rapidly as possible.

45
Q

Pain med you can use when Bp is too low for morphine?

A

Fentanyl 1mcg/Kg IV

Fentanyl Intranasl 2mcg/Kg
Excellent for children or when
there is no line in

46
Q

Morphine and Hypotension

A

The chief adverse effect of opiates is RESPIRATORY DEPRESSSION; however, they cause HYPOTENSION via vascular dilation resulting from relaxing smooth muscle. This reduces Bp most especially in those who are volume depleted or already severely hypotensive.

Alternately, it may assist in bringing DOWN high blood pressures as occur s/t fear and agitation in MI or other urgent circumstances.

47
Q

Morphine Dose IV/IM

A

0.1mg/Kg

A usual dose is 4mg IM or IV

Typically given with 4 mg Zofran to head off nausea and vomiting

If it causes itching, give 25mg Benadryl IV

48
Q

Ketamine Rescue Dose for pain relief

A

0.15mg/Kg

You can ADD this to morphine for the patient in SEVERE pain

May cause dizziness

49
Q

Cincinnati stroke scale

A

Facial droop, i’m drift, slurred speech,

50
Q

Sort bells from a stroke

A

Ibero float. Uneven equals bells. Even eyebrows is stroke

51
Q

Diltiazem Rescue Dose

A

20mg over 2 min IV bolus

10mg for little old ladies or you’ll bottom out their rate

Official dosing is .25mg/Kg. You can repeat the bolus in 15 minutes if tolerated but inadequate rate/bp reduction.

If response is adequate, maintenance is 10mg/hr for up to 24 hrs.

52
Q

CBIGKDrop

A

Calcium Gluconate: you can give this to her from mine. Calcium chloride delivers more calcium but must be given to a central line, so usually calcium Gluconate

53
Q

Internal derangement

A

This is what you say about an injured joint when you’ve x-rayed it and you really need an MRI to see

54
Q

Ludwigs angina

A

Swollen submandibular glands restrict airway

Infectious mixed mouth flora, aerobes and anaerobes
Penn g with metronidazole should cover
Could replace penn with ampicillin
Could use Augmenting mono

Ent consult STAT. May have to incubate i

Decadron steroid for swelling
Antibiotic IV

55
Q

Cellulitis no pus no sound

What is it most likely?

A

Strep. Give Keflex po or Clinda 600 q 8 hrs IV

56
Q

Cellulitis with pus or wound

Most likely…

A

Have to cover MRSA and Pseudomonas until culture comes back so…
Vanco, Flagyl & Cefepime IV.

15 mg/Kg Vanco 2g Cefepime & 500mg Flagyl

Switch out a pro for Cefepime if Penn allergic

57
Q

UTI in the ED

A

We don’t use nitrofurantoin because it’s bacteriostatic so they get ceftriaxone unless theyre pen allergic in which case they get Cipro.

If nursing home with significant comorbidities Zosyn IV

58
Q

Torus fracture

A

Buckle fracture, buckling of the cortex seen as a little bulging that disrupts The line of the bone

Look for it in the radius in FOOSH

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