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ER Flashcards

1
Q

PET MAC

A 
6 deadly causes of chest pain 
PE
Esophageal rupture (Boerhaave syndrome) 
Tension pneumo 
MI 
Aortic dissection 
Cardiac tamponade
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2
Q

Who gets admitted for syncope?

A 
San Fran Syncope Rule (CHESS) 
CHF (hx or suspicion) 
Hematocrit <30% 
EKG abnormalities 
SOB w/ syncope episode 
Systolic BP <90 post arrival to ED
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3
Q

What is the treatment for HTN emergency in the ER?

A

amlodipine (CCB), nicardipine (CCB) or clonidine (alpha 2 blocker)

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4
Q

What are the most common causes of acute pancreatitis?

A

alcohol abuse and cholelithiasis

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5
Q

Abdominal pain that is relieved by leaning forward?

A

acute pancreatitis

other sxs also include: 
N/V, epigastric pain that radiates to the back 
diminished bowel sounds
fever 
Grey Turner sign, Cullen sign

DDx: hepatitis, AAA, GERD, MI, cholelithiasis

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6
Q

What is the treatment for PID?

A

ceftriazone 250mg IM in a single dose + doxycycline 100mg PO bid for 14 days +/- metronidazole 500mg PO bid for 14d

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7
Q

What is the definition of orthostatic hypotension?

A

decrease in systolic BP by 20mmHg or diastolic BP drop by 10mmHg

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8
Q

In a pt who comes in for hypertensive emergency, we don’t normally want to lower their BP too fast, except with what condition?

A

aortic dissection

via nicardipine

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9
Q

What is the initial test of choice for someone with heart failure?

A

TTE - transthoracic echo

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10
Q

NYHA class 1

A

sxs only occur with vigorous activities, such as playing a sport
pts are nearly asymptomatic

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11
Q

NYHA class 4

A

symptoms occur at rest. incapacitating

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12
Q

What is the treatment for CHF in the ER?

A

sodium restriction
Lasix (furosemide - loop diuretic)
ACEI

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13
Q

What are risk factors of nephrolithiasis?

A 
gout
hyperparathyroidism
PUD
crohn's disease
IBD
family or personal hx
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14
Q

What are concerning sxs suggestive of MI?

A

diaphoresis and vomiting

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15
Q

What are the components are heart score?

A 
story 
EKG changes 
age 
risk factors (DM, HTN, obesity, family hx) 
troponin
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16
Q

What PE needs to be done for someone who had a syncopal episode?

A

Neuro
orthostatic
possible rectal for occult blood

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17
Q

What specifically should you look for on EKG for pts who had a syncopal episode?

A 
BLOW Hard 
Brugada
LOng QT
WPW
HOCM
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18
Q

What is the most common chronic arrhythmia?

A

A. fib

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19
Q

Describe what A. fib looks like

A

irregularly irregular rhythm ww/ narrow QRS, no P waves, just fib waves at 350-600 bpm w/ ventricular rate of 80-140

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20
Q

What are possible complications of a. fib?

A

hypoTN, decreased CO, thromboembolism, cardiomyopathy

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21
Q

What is the difference between stable and unstable a.fib?

A

unstable: hypoTN, AMS, refractory CP, acute HF

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22
Q

What is the difference in treatment between stable and unstable a.fib?

A

both: CHADS-VASc2 - to determine the need for
unstable: synchronized cardioversion
stable: rate control: BB, CCB
if young w/ long afib: synchronized cardioversion perferred (after 3-4 weeks on anticoags)

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23
Q

Describe what A. flutter looks like

A

regular rhythm

saw tooth waves at 250-350 bpm

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24
Q

What is the difference in treatment between stable and unstable a. flutter?

A

Stable: vagal, BB, CCBs (or cardiovert if <48 hours)

Unstable: synchronized cardioversion

ultimate: radiofrequency ablation

IV ibutilide is good for converting flutter to sinus in acute cases
Amiodarone can be used post cardioversion for chronic management

everyone gets warfarin anticoagulation? keeping INR between 2-3

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25
Q

What is SVT?

A

regular rapid rhythm of >150

MC d/t impulse re-entry or ectopic pacemaker above bundle of his

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26
Q

What is the treatment for SVT?

A

Unstable: cardiovert
Stable: vagal maneuvers first; then 6mg adenosine
if no response in 2 min, give 12mg adenosine

if wide complex SVT, treat as if VTach unless known WPW: procainamide

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27
Q

What does V. Tach look like?

A

3+ PVCs >100bpm

prolonged QT predisposes to V.Tach

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28
Q

Torsades de Pointes is most commonly caused by what?

A

hypomagnesemia or hypokalemia

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29
Q

What are the two shockable rhythms?

A

pulseless v. tach and v. fib

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30
Q

What defines a HTN emergency?

A

diastolic BP >115 mmHg with evidence of end organ damage

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31
Q

What are some causes of HTN emergency in pts without hx of HTN?

A

eclampsia - pregnancy

acute glomerulonephritis

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32
Q

What is the treatment in the ER for HTN emergency?

A

amlodipine (CCB) or clonidine (alpha 2 agonist)

MAP should be gradually reduced by 10 - 20% in the first hour

the only time you rapidly reduce BP is for pts with aortic dissection

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33
Q

How does pulmonary HTN affect the heart?

A

decrease preload and decrease CO

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34
Q

What is the pathophys of cardiogenic shock?

A

decreased CO with adequate volume but evidence of tissue hypoxia

d/t MI, myocardiditis, valve dysfunction, cardiomyopathy, arrhythmias

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35
Q

What is the most common chronic arrhythmia?

A

A. fib

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36
Q

What is CHESS used for?

A

to determine if someone w/ syncope needs to be admitted

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37
Q

What is the first line treatment for stable a. fib?

A

rate control
BB - metoprolol
or
CCB - diltaizem

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38
Q

What is the first line treatment for unstable a. fib?

A

synchronized cardioversion

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39
Q

What are the components of CHADSVASC2?

A 
CHF
HTN
Age > 75 (2 points) 
DM
Stroke (2 points) 
Vascular dz
Age 65-74
Sex - female
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40
Q

What is the first line therapy for an unstable bradyarrythmia?

A

unstable: AMS, hypotension, acute heart failure, refractory CP

atropine

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41
Q

What is the first line treatment for unstable tachy arrythmia?

A

synchornized cardioversion

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42
Q

What is the first line treatment for stable, wide tachy arrythmia?

A

amiodarone

narrow QRS? vagal –? adenosine

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43
Q

How do you treat HTN emergency?

A

amlodipine (CCB - 2.5mg)

clonidine (alpha 2 - 0.2mg)

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44
Q

What is the initial tx for most symptomatic pts with CHF?

A

ACEI + diuretic

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45
Q

What is the initial test of choice for heart failure?

A

TTE (echo) - noninvasive assessment of anatomy and function

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46
Q

What % occlusion causes angina?

A

@ rest 90%

w/ exercise 75%

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47
Q

What is the treatment for variant angina?

A

CCB + nitrate

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48
Q

What is the treatment for acute bronchitis?

A

symptomatic, bronchodilators

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49
Q

What is the treatment for acute bronchiolitis?

A

humidified O2

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50
Q

What is the treatment for epiglottis?

A

2nd/3rd gen cephalosporins

Ceftriaxone/ceftaxrine

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51
Q

What is the treatment for croup?

A

dexamethasone (0.6mg/kg po x 1) + humidified O2

max of 10 or 20mg total?

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52
Q

What is the treatment for pertussis?

A

Macrolide (erythromycin)

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53
Q

What is the treatment for acute pericarditis?

A

NSAIDs

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54
Q

What causes aortic regurgitation?

A 
Rheumatic heart disease, endocarditis 
Marfans syndrome 
syphilis 
SLE 
ankylosing spondylitis (bamboo spine)
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55
Q

What is the pathophysiology of aortic regurgitation?

A

Aortic valve fails to close during diastole which leads to blood flow back into LV from aorta at the same time that blood is flowing from LA to LV – this leads to LV volume overload –> LVH –> CHF

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56
Q

What are the signs and sxs of aortic regurgitation?

A

diastolic decrescendo blowing murmur heard at the LUSB

widened pulse pressures

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57
Q

What increases the intensity of the aortic regurgitation murmur?

A

squatting, sitting forward, hand grip (think anything straining)

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58
Q

What decreases the intensity of the aortic regurgitation murmur?

A

decrease venous return: valsalva
inspiration
nitrates

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59
Q

What is the Austin Flint murmur and what is it associated with?

A

associated with aortic regurg
mid-late diastolic rumble at the apex secondary to retrograde regurgitation jet competing with antegrade flow from LA into LV (functional mitral stenosis)

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60
Q

How is aortic regurgitation diagnosed?

A

Echo

CXR might show cardiomegaly and some pulmonary congestion if bad

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61
Q

What is the treatment for aortic regurg?

A

We want to decrease afterload (in hopes that this will decrease the back flow into LV?)
This is done with nitrates, ACEI, hydralazine (vasodilator)
(NOT BB–> they decrease HR and thus increase the amount of time in diastole)

surgery for those pts with LV decompensation: decreased EF

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62
Q

What causes mitral stenosis?

A

rheumatic heart disease MC

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63
Q

What is the pathophysiology of mitral stenosis?

A

obstruction of flow from LA to LV causing blood to back up in LA leading to pressure and volume overload –> pulmonary congestion/HTN

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64
Q

What is the clinical manifestation of mitral stenosis?

A

dyspnea MC sx
hemoptysis
a. fib
dysphagia (d/t esophageal compression from enlarged LA)
opening snap, early diastolic rumble at apex (low-pitched)

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65
Q

What age group presents with mitral stenosis?

A

since the MC cause is rheumatic heart disease the mean age is 30s-40s

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66
Q

What increases the intensity of mitral stenosis?

A

increasing venous return via squatting or left lateral decubitus position

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67
Q

What decreases the intensity of mitral stenosis?

A

decrease venous return by valsalva or inspiration

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68
Q

What is the treatment for mitral stenosis?

A

percutaneous balloon valvuloplasty/valvotomy

loop diuretics and Na+ restriction if congestion sxs

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69
Q

What is the most common valvular disease?

A

Aortic stenosis

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70
Q

What is the pathophysiology of aortic stenosis?

A

normal area: 3-4 cm2
sxs: <1cm2

stenosis leads to LV outflow obstruction –> fixed CO –> increases afterload (pressure overload) –> LVH

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71
Q

What is the clinical manifestations of aortic stenosis?

A

dyspnea (mc sxs)
Angina
Syncope (exertional)
CHF (worst prognosis)

narrowed pulse pressures (the opposite of aortic regurg)

once pts start having sxs their life span decreases dramatically if valve replacement not done

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72
Q

What is the murmur for aortic stenosis?

A

systolic ejection crescendo-decrescendo murmur at RUSB that radiates to carotid

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73
Q

What decreases murmur intensity in aortic stenosis?

A

decrease in venous return (valsalva, standing) handgrip

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74
Q

What increases murmur intensity in aortic stenosis?

A

increase in venous return: squatting, leg raise, leaning forward

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75
Q

How is aortic stenosis dx?

A

Echo

LVH on EKG

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76
Q

What is the treatment for aortic stenosis?

A 
no medication treatment 
surgery is the only effective treatment 
valve replacement for those sx pts 
percutaneous aortic valvuloplasty 
intraortic balloon pump
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77
Q

What is the MC cause of mitral regurg?

A

mitral valve prolapse

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78
Q

What is the pathophys of mitral regurg?

A

blood flows from LV to LA – LV volume overload –> dilation –> decrease CO

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79
Q

What are the clinical manifestations of mitral regurg?

A

pulmonary edema
hypotension
dyspnea

chronic: a. fib

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80
Q

What is the murmur associated with mitral regurg?

A

blowing, holosystolic murmur @ apex with radiation

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81
Q

Humeral head fracture can cause what nerve damage?

A

brachial plexus or axillary nerve

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82
Q

Humeral shaft fracture can cause which nerve damage?

A

radial nerve –> wrist drop

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83
Q

Claw hand is which nerve damage?

A

ulnar nerve

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84
Q

Navicular fracture

A

anatomical snuff box tenderness

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85
Q

Which elbow dislocation is most common?

A

posterior MC

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86
Q

Which shoulder dislocation is most common?

A

anterior

posterior is much less common and typically from muscle spasms d/t seizures, getting struck by lightening, and some MCVs

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87
Q

Monteggia fx

A

proximal ulnar fx with radial head dislocation at elbow

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88
Q

Galeazzi fx

A

distal radial shaft fx + dislocation of distal ulna

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89
Q

Beck’s Triad

A

JVD
hypotension
muffled heart sounds

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90
Q

What is the treatment for asthma?

A

albuterol 2.5mg q 20-30 min

albuterol, beta agonist, will increase HR

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91
Q

Which ABX should be given to a pt with COPD flare?

A

azithromycin (Z-pack)

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92
Q

A pts CXR shows PNA, when do you admit them?

A

CURB65

Age >/=65, SBP <90 or DBP <60, confusion, BUN >19, RR >/=30

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93
Q

What is the PNA tx for an inpt?

A

azithromycin + ceftriaxone

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94
Q

What is the MC cause of hemoptysis?

A

bronchitis

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95
Q

What is the treatment for croup?

A

dexamethasone 0.6mg/kg po x 1 (max dose 20 mg)

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96
Q

Who gets tested for influenza?

A

<2yo, >/=65, pregnant, other underlying heart or lung dz)

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97
Q

What is the treatment for influenza?

A

tamiflu (oseltamivir) or relenza (zanamivir)

only treat in sxs started <72 hours ago

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98
Q

What is the cause of whooping cough?

A

bordetella pertussis (there’s a vaccine for it)

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99
Q

What is the treatment for pertussis?

A

o2, neb,

abx only to decrease contagiousness (macrolides)

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100
Q

What pathogens cause CAP?

A

community acquired PNA

s. pneumo (MC), mycoplasma (MC atypical “walking” PNA), h. flu

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101
Q

What is the common pathogen of PNA in alcoholics?

A

klebsiella

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102
Q

RSV

A

respiratory syncytial virus
common lung and URI in children <2 yo
tx: supportive treatment

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103
Q

What is one important assessment question you must ask pts in the ED with asthma or COPD exacerbation?

A

Have you ever been intubated before?

*always ask triggers – what were they doing when this began

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104
Q

How does albuterol work in asthma?

A

binds to beta receptors that activates to cAMP and decreased Ca2+ release –> smooth muscle relaxation

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105
Q

What are the most common causes of pleural effusion?

A

CHF, PNA, CA, PE

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106
Q

Transudate

A 
typically bilateral (unlike exudate) 
low protein
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107
Q

Exudate

A

typically unilateral

high in protein

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108
Q

What is the treatment for pleural effusion?

A

thoracentesis (typically done by IR)

or chest tube if large

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109
Q

How is pleural effusion dx?

A

pleural friction rub to auscultation

blunting of the costophrenic angles (seen when fluid is >250ml)

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110
Q

What are the signs and sxs of tension pneumothorax?

A

increased JVP, pulsus paradoxus, hypoTN
unilateral pleuritic CP, decreased breath sound

decreased lung markings on CXR w/ respiratory view

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111
Q

What is the treatment for pneumothorax?

A

tension: needle decompression in the 2nd ICS at MCL (heaven is above and hell is below a rib)

chest tube for other pneumothorax that are >15% of diameter of hemithorax (2-3cm)

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112
Q

What questions must you ask when you assessing risk of PE?

A 
hemoptysis 
O2 sat 
Hormone use 
age >50 
hx DVT or PE 
surgery or trauma within last 4 weeks

tachy?
travel within the last 3 months

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113
Q

What is the treatment for PE?

A

Anticoagulation –> LMWH (Lovenox or enoxaparin)

IVC filters only for pts who are stable but can not have anticoagulation treatment

TPA only considered for pts who are hemodynamically unstable

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114
Q

White out on CXR

A

ARDS

spares the costophrenic angles

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115
Q

How is ARDS dx?

A

white out on CXR
ABG PaCO2/FIO2 <200 refractory to 100% oxygen
catheter wedge pressure <18 (>18 = cardiogenic pulmonary edema)

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116
Q

What is the treatment for ARDS?

A

CPAP or mechanical ventilation (tx underlying condition)
keep O2 >90%
PEEP prevents airway collapse

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117
Q

How does someone with an anterior shoulder dislocation present?

A

arm abducted, externally rotated with loss of deltoid contour

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118
Q

What is the work up and treatment for anterior shoulder dislocation?

A

rule out axillary nerve injury
reduction with use of propofol +/- ketamine
inferior –> external rotation –> abduction of the shoulder

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119
Q

Light bulb or ice cream cone shape to shoulder xray

A

posterior shoulder dislocation

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120
Q

Proximal humerus fracture

A

FOOSH or direct blow
*common side of fx with breast ca metastasis

risk of brachial plexus or axillary nerve injury

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121
Q

What splint would you do for a humeral shaft fracture?

A

sugar tong

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122
Q

Humeral shaft fx

A

FOOSH or direct trauma
radial nerve injury risk –> wrist drop

tx: sugar tong splint

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123
Q

Supracondylar humerus fracture

A

FOOSH with hyperextended elbow, MC kids 5-10yo

risk of medial nerve and brachial artery injury

+ fat pads on elbow xray

tx: displaced: ORIF, nondisplaced: posterior splint

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124
Q

What is the MC bone fx in kids?

A

clavicle fracture

risk of brachial plexus injury or PTX

tx: mid 1/3: sling 4-6 weeks
proximal 1/3: ortho consult

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125
Q

Radial head fracture

A

FOOSH

posterior fat pad sign or displaced anterior fat pad

tx: sling if nondisplaced

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126
Q

Olecranon fracture

A

direct blow

risk of ulnar nerve damage

tx: reduction

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127
Q

Galeazzi fx

A

mid-distal radial shaft fx + dislocation of distal ulna
FOOSH
tx: ORIF

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128
Q

Monteggia fx

A

proximal ulnar fracture + anterior dislocation of radial head

direct blow to arm

tx: ORIF

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129
Q

What is the MC dislocation in kids?

A

elbow (posterior)

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130
Q

What is the MC carpal fracture?

A

scaphoid fracture (snuff box tenderness –> thumb spica splint)

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131
Q

Colles fracture

A

distal radius fracture w/ dorsal/posterior angulation
FOOSH w/ wrist extension (increase incidence post menopausal)

tx: sugar tong splint

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132
Q

Smiths Fracture

A

the opposite to colles fx

fall oto a flexed wrist
distal radius fx + anterior dislocation

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133
Q

Barton fracture

A

intra-articular distal radius fracture w/ carpal dislocation

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134
Q

perilunate dislocation

A

lunate and capitate no longer articular

but lunate still articulates with radius

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135
Q

Lunate dislocation

A

lunate doesnt articulate w/ either radius or capitate –> emergency

“piece of pie” sign AP
“spilled teacup” lateral xray

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136
Q

Lunate fx

A

most emergent carpal fracture

avascular necrosis of this bone can lead to Kienbocks disease

tx: immobilize (refer to ortho?)

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137
Q

Boxers fracuter

A

fracture to the neck of the 5th metacarpal bone
communicated transverse fracture +/- loss of knuckle on exam

also check for bites (from fight –> tx: augmentin)

reduction
ulnar gutter splint

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138
Q

Bennett Fracutre

A

intra-articular fracture through base of 1st metacarpal bone with distal fragment dislocated radially and dorsally d/t abductor pollicus longus

ORIF
thumb spica for temporary stabilization

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139
Q

Acetabular fracture

A

MC pelvic fracture

d/t high-impact injury

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140
Q

Hip dislocations

A

emergencies
MC posterior
Trauma MC cause
complications: avascular necrosis, sciatic nerve injury, DVT, bleeding

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141
Q

Shortened leg, internally rotated and adducted

A

hip dislocation

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142
Q

hip pain with shortened leg, externally rotated and abducted

A

hip fx

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143
Q

Legg Calve Perthes

A

idiopathic avascular necrosis of femoral head in kids d/t ischemia of capital femoral epiphysis
MC 4-10yo
M>F

painless limping

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144
Q

Slipped Capital femoral epiphysis

A

femoral head slips posterior and inferior at growth plate
MC age 7-16yo d/t growth spurt
tx: non-weight bearing
ORIF

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145
Q

Cauda eqine

A

EMERGENCY
nerve root compression of L4-L5 or L5-S1
urinary retention, loss of bladder/bowel control (decreased rectal tone)

tx: immediate surgical decompression

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146
Q

Saddle Anesthesia

A

loss of sensation in butt, inner thigh, perineum

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147
Q

Who is at increased risk of osteomyelitis?

A

IVDU, DM/immunocomp, children, sickle cell

overlying infection or open fracture

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148
Q

Which bone fractures are more likely to spread infection throughout the blood?

A

pelvis, vertebrae, clavicles/sternum

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149
Q

What is the treatment for osteomyelitis?

A

need for tissue cultures for sensitivity
MSSA: nafcillin 2g IV q4h, cefazolin 2gIV q8h
MRSA: vancomycin 30mg/kg IV q24h (divided into 2-3 doses/day)

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150
Q

Monoarticular joint swelling

A

septic joint until proven otherwise

> 10,000 WBC with a left shift is dx on arthrocentesis

knee is MC

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151
Q

What is the treatment for septic arthritis?

A

depends on the type of bacteria –> arthrocentesis, send for gram stain and culture

Gram + cocci: nafcillin
Gram - cocci or gonococcus: ceftriaxone
Gram - rods: ceftriaxone + anti-pseudomonal aminoglycoside (gentamicin)
No organism seen: nafcillin or vanc + ceftriaxone

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152
Q

How is osteomyelitis dx?

A

bone aspiration = gold standard

elevated ESR
periosteal reaction on xray

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153
Q

Costochondritis

A

acute inflammation of rib, clavicle, and/or sternal joints d/t viral infection
substernal pleuritic CP thats worse with arm movement
TTP and pinpoint pain to 2nd-5th costochondral junctions

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154
Q

What is the treatment for bursitis?

A

inflammation of bursa over bony prominence commonly d/t gout, inflammation, trauma, infections
limited ROM with flexion

tx: NSAIDs, local steroid injections
rest

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155
Q

Podagra

A

the 1st MTP joint that is the MC involved with gout

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156
Q

How can you tell gout from psuedogout?

A

gout: negative birefringent needle shaped crystals on arthrocentesis

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157
Q

Gout

A

uric acid depostion in soft tissue, joints, and bone

MC d/t underexcretion of uric acid

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158
Q

What foods should be avoided in pts with gout?

A

high purine rich foods like alcohol, liver, seafood, yeast

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159
Q

What meds should be avoided in pts with gout?

A

diuretics, ACEI, ARB, ethambutol, aspirin

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160
Q

Punches out lesions or mouse bites on xray

A

gout

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161
Q

What is the treatment of gout?

A

acute: NSAIDS (not ASA), + colchicine
chronic: allopurinol (increases uric acid excretion

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162
Q

A pulled muscle is also called….

A

strain

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163
Q

Epigastric abdominal pain DDx

A

pancreatitis, PUD, MI, aortic aneurysms, gastritis

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164
Q

LLQ abdominal pain DDx

A

diverticulitis, ischemic colitis, appendicitis, gynecologic disorders

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165
Q

RLQ abdominal pain DDx

A

appendicitis, crohns disease, diverticulitis, ovarian torsion, gynecologic disorders

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166
Q

Abrupt vs waxing and waning abdominal pain

A

abrupt: perforation of a hollow viscus

waxing and waning: colicky, suggests obstruction

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167
Q

Esophagitis

A

pill vs infection induced

Pill: doxyxycline, NSAIDs, bisphoshonates, KCl, quinidine
Infectious: MC in immunocompromised: candida, HSV, CMV

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168
Q

Odynophagia

A

painful swallowing

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169
Q

How is esophagitis dx?

A

esophagoscopy with biopsy and culture

candida: air contrast barium swallow shows ulceration and plaques

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170
Q

What is the treatment for infectious esophagitis?

A

candida: ketoconazole or fluconazole
HSV: acyclovir

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171
Q

How is pill esophagitis avoided?

A

take pill with lots of water and sit upright for 30min after taking pill

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172
Q

Mallory Weiss tear

A

partial thickness lacerations of the gastroesophageal junction caused by forceful emesis
self limiting in most people
more worrisome in alcoholic pts d/t risk of ruptured vericies
Dx: EGD
Tx: assess hemodynamics

173
Q

PUD

A

erosion of mucosa that produce pain and can perforate into a blood vessel or into the peritoneal cavity

common cause of upper GI bleed
commonly d/t H. pylor

RF: smoking, alcohol, asa/nsaid use, fam hx

174
Q

CP of PUD

A

burning/gnawing pain in epigastric region relieved by antacids, H2 blockers or PPIs

gastric ulcers: worse after eating
Duodenal: relieved with eating

175
Q

PUD perforation presenstation

A

abrupt onset of epigastric pain w/ vomiting and diaphoresis

diffuse abdomen with rigidity and guarding

176
Q

Work up for PUD

A

CBC (H&H)
type and cross
PT/PTT
xray (free air = perforation)

177
Q

What is the treatment for PUD?

A

uncomplicated H.pylori: clarithromycin, amoxicillin, PPI (avoid EtOH, caffeine, NSAIDs)
Hemorrhage: fluids, packed RBCs, IV PPI

perforation: NG suction, IV fluids, Cefoxitin, surgery

178
Q

4Fs

A 
risk factors for acute cholecystitis 
female
fat
forty
fertile
179
Q

How do pts with cholecystitis present?

A

constant, cramping RUQ or epigastric pain
+/- radiation to scapula
N/V
worse postprandial with fatty foods

RUQ tenderness –> Murphy’s sign

+/- fever, jaundice

DDx: biliary colic

180
Q

How is cholecystitis dx?

A

elevated WBC
+/- elevation in LFTs and bilirubin (esp if stone in common bile duct vs cystic duct)
US
HIDA - outpt

181
Q

What is the treatment for cholecystitis?

A

IV fluids and bowel rest
surgical consult

*if stones are found coincidentally on scan, no tx required

182
Q

How is biliary colic different from cholecystitis?

A

severe colicky pain that lasts several hours without fever or elevation in WBC, LFTS or bilirubin
tx: antispasmoidcs (dicyclomine)

183
Q

Cholangitis

A

bacterial infection of the biliary system d/t impaction of gallstone in the common bile duct

Charcot’s triad: RUQ pain, fever, jaundice
Reynold’s Pentad: + hypotension, AMS

184
Q

Charcot’s triad

A

seen with cholangitis

RUQ pain, fever, jaundice

Ryenold’s pentad: + hypotension, AMS

185
Q

How is cholangitis dx:

A

RUQ US
AST/ALT 2-3x normal
total bil >3mg/dL

186
Q

What is the tx for cholangitis?

A

ampicillin + gentamicin or ceftriaxone + metronidazole
+
urgent endoscopic cholangiogram (endoscopic sphincterotomy) with drainage of infected bile
removal of gallbladder 2 weeks later

187
Q

Acute pancreatitis

A

inflammation fo the pancrease d/t inappropriate intrapancreatic activation of enzymes

MC cause: EtOH, followed by gallstones

CP: N/T, epigastric pain that radiates to the back, relieved by leaning forward
epigastric tenderness, diminished bowel sounds, fever, jaundice
Grey-Turners: flank ecchymosis
Cullen Sign: periumbilical ecchymosis

188
Q

CP of acute pancreatitis

A

CP: N/T, epigastric pain that radiates to the back, relieved by leaning forward
epigastric tenderness, diminished bowel sounds, fever, jaundice
Grey-Turners: flank ecchymosis
Cullen Sign: periumbilical ecchymosis

189
Q

Grey Turner sign vs Cullen sign

A

Grey Turner: flank ecchymosis

Cullens: periumbilical ecchymosis

190
Q

Acute pancreatitis labs

A

amylase (rises first)
lipase (more specific)

CT
US only used to r/o gallstone cause

191
Q

Rnson criteria

A

and apache 2

clinical prediction rules for severity (mortality) of acute pancreatitis

192
Q

What is the treatment for acute pancreatitis?

A

IV fluids (250-500mL/h)
Fentanyl/hydromorphone (or meperidine) preferred over morphine (d/t sphincter of Oddi spasm)
NG tube for decompression

admission: severe pancreatitis w/ instability or end organ damage

193
Q

What is the DDx of acute pancreatitis?

A

perforated duodenal ulcer, acute cholecystitis, acute SBO, leaking AAA, renal colic, acute mesenteric ischemia

194
Q

Which age is most likely to get appendicitis?

195
Q

CP of acute appendicitis?

A

periumbilical pain that moves to RLQ
McBurnery point tenderness, rebound tenderness
Rovsing sign
Anorexia, N/V, +/- fever

196
Q

What is the treatment for appendicitis?

A

ABX while waiting for surgery

Ceftraizone (Rocefin) or Pip/Tazo (Zosyn)

197
Q

Toxic megacolon

A 
nonobstructive dilation (>6cm) of colon + signs of systemic toxicity 
etiology: UC, chorhns, C. diff, infectious, radiation, ischemia

CP: fever, N/V?D, adb. pain, rectal bleeding, tenesmus
tachycardia, hypotension, AMS

Dx: xray

Tx: bowel decompression, bowel rest, NG tube, ABX?

198
Q

What causes toxic megacolon?

A

UC, chorhns, C. diff, infectious, radiation, ischemia

199
Q

How is toxic megacolon dx?

200
Q

What is the tx for toxic megacolon?

A

bowel decompression, bowel rest, NG tube, ABX?

if refractory: colostomy

201
Q

SBO

A

surgical adhesions MC > tumors> hernias> strictures, crohns

CP: cramping, inability to pass stool or gas, vomiting, abd distension
high pitched bowel sounds

Dx: Xray - air fluid levels (free air under the diaphragm = perf)

Tx: NG tube, NPO, IV hydration +/- surgery if no improvement in 12-24 h

202
Q

How is SBO dx?

A

xray - air fluid levels

203
Q

How is SBO tx?

A

NG tube, NPO, IV hydration, +/- surgery

204
Q

Large bowel obstruction

A

MC colorectal carcinoma > volvulus > diverticular disease > hernia, foregin body, IBD

CP: distention, postprandial cramping/bloating, bowel habit changes, vomiting

Dx: Xray - haustral markings seen

Tx: NG tube, NPO, IV hydration –> surgery

205
Q

Voluvulus

A

twisting of bowel more than 180 degrees at mesenteric attachment site
MC sigmoid colon
tx: endoscopic decompression

206
Q

Anal fissure

A

linear tears distal to the dentate line
usually in the posterior midline
MC cause of anal pain
can be associated with Crohn’s or UC

burning and stinging during defecation, minimal rectal bleeding

tx: high fiber diet, sitz bath after BM

207
Q

Anal fistula

A

abnormal tracts from the anal canal, most often d/t external damage of an anorectal abscess, but can also come from diverticulitis, appendicitis, or IBD
CP: bloody or foul smelling discharge, recurrent inflammation
Tx: surgery

208
Q

Anal abscess

A

often d/t bacterial infection of anal duct/glands
MC s. aureus, e. coli
anorectal swelling, pain worse with sitting, coughing, defecation
Tx: I&D followed by WASH: warm water, analgesics, sitz baths, high fiber diet

209
Q

What is the difference between internal and external hemorrhoids?

A

dentate line
internal = above, painless rectal bleeding
external = below, painful bleeding

210
Q

how can you tell the difference between thrombosed and not thrombosed hemorrhoids?

A

thrombosed are hard masses on exam

not thrombosed are cushion like

211
Q

What are the different classifications of hemorrhoids?

A

1st degree = simple internal
2nd degree = prolapsed internal that reduce spontaneously
3rd degree = prolapsed internal must be reduced manually
4th degree = can not be reduced

212
Q

How do you dx internal hemorrhoids?

A

anoscopy or flexible endoscopy

213
Q

What is the treatment for hemorrhoids?

A

conservative: high fiber diet, fluids, stool softener, sitz bath, topical analgesic ointment, hydrocortisone cream
External thrombosed hemorrhoid can be resected in the ED

internal: refer to colorectal surgeon

214
Q

Gastroparesis

A

slowed gastric emptying

MC risk factors: DM, smoking mary jane

215
Q

Gastritis

A

superfical inflammation/irritation of stomach mucosa

MC cause: H. pylori
NSAIDS/ASA: second MC d/t decrease in prostaglandin production
CP: epigastric pain, N/V, anorexia
Dx: endoscopy is gold standard
Tx: CAP (triple therapy) Clarithromycin + amoxicillin + PPI

216
Q

What is the CP for gastritis?

A

epigastric pain, N/V, anorexia

217
Q

What is the gold standard for dx of gastritis?

218
Q

What is the treatment for gastritis?

A

CAP (triple therapy) Clarithromycin + amoxicillin + PPI

since H. pylori is the MC cause

219
Q

Colitis

A

same inflammation/irritation of superficial mucosa as in gastritis but specifically at to colon

tx: ciprofloxacin or metronidazole
cipro: risk of C. diff (consider augmentin)

220
Q

What is the treatment for colitis?

A

ciprofloxacin or metronidazole

cipro: risk of C. diff (consider augmentin)

221
Q

Gastroenteritis

A

Viral( norovirus in adults, rotavirus in kids)

Bacterial (salmonella, shigella, campy)

222
Q

What is the treatment for gastroenteritis?

A

rehydrate, antiemetic, BRAT diet

PO challenge prior to d/c

223
Q

Gut motility is affected by what?

A

diet, activity level, anatomic lesions, neurologic conditions, medications, toxins, hormones, rheumatologic conditions, infection, psych

224
Q

Acute constipation

A

SBO until proven otherwise

keep suspicion high tho, don’t just assume constipation d.t hx of constipation

225
Q

What tests must your run for a pt with constipation?

A

CBC, electrolytes (BMP), thyroid panel

hypothyroidism or hyperparathryoidism can cause constipation
increase CA2+, decrease Mg2+, decrease K+

226
Q

What is the treatment for constipation?

A

metamucil (psyllium)
milk of magnesia
manual fecal disimpaction

227
Q

Diarrhea

A

3+ watery stools per day

85% have infectious etiologies

228
Q

Crohn’s disease

A

part of IBD

segmental ulceration of the GI tract ANYWHERE
“skip lesions”
cobblestoning
no blood
diarrhea for several years, anorexia, weight loss

229
Q

What is the treatment for Crohn’s disease?

A

ED: IVF, parenteral analgesia (viscus lidocaine), bowel rest, correct electrolyte abnormalities if present
prednisone gives sx relief but doesnt alter dz

labs: CBC, type and cross, plain filsm for poss obstruction or toxic megacolon

230
Q

What are some complications of Crohns disease?

A

intra abdominal abscess, fissures, fistulas, toxic megacolon, malnutrition, anemia

Extrainestinal: arthritis, uveitis, nephrolithiasis, hepatobiliary dz, thromboemolic dx, skin disease

231
Q

Ulcerative colitis

A

ALWYAS includes the rectum
continues proximally up the colon
+ bloody diarrhea
complete remission between flares

232
Q

What is the treatment for ulcerative colitis?

A

IVF, parenteral analgesia, bowel rest, correction of electrolyte abnormalities
avoid anti-diarrheals d/t risk of toxic megacolon

233
Q

What are possible complications of ulcerative colitis?

A

MC GI hemorrhage, perforation
higher risk of colon CA

extraintestinal: ankylosing spondylitis, peripheral arthritis, uveitis, hepatobiliary dz, erythema nodosum, episcleritis

234
Q

Recent travel to mexico or asia and now has diarrhea

A

enterotoxigenic e. coli (same with undercooked beef)

235
Q

What is the treatment for C. diff?

A

mild: metronidazole 500mg PO for 10-14 days
Severe: PO vancomycin 125-250mg

236
Q

Potato salad and now has diarrhea

A

staph aureus or salmonella (d/t mayo)

237
Q

What is the most common cause of upper GI bleed?

A

PUD (50%)

gastritis, mallory weiss tear, esophgeal varices

238
Q

What is the most common cause of lower GI bleed?

A

Young children: Meckles diverticulum, IBD, polyps
Adults: diverticulosis, IBD, neoplasma
60+: diverticulosis, neoplasms, angiodysplasia

239
Q

Diverticular disease

A

herniations of the colonic mucoas through the muscularis propria
thought to be caused by a low fiber diet
leads to less stool mass and constipation –> higher intracolonic pressures –> muscular hypertrophy –> promotes herniation

sigmoid colon (LLQ) MC

increasing incidence with age

only a problem if it causes pain, bleeding, diverticulitis

MC cause of lower GI bleed

240
Q

Where is divertiuclar disease most common?

A

LLQ - sigmoid colon

241
Q

Diverticulitis

A

inflammatory condition (d/t infection/obstruction) leading to microperforation of the diverticulum which is usually d/t the lodging of feces in the pouch –> LLQ pain worse with BM, fever, dysuria

242
Q

What is the test of choice for diverticular disease?

243
Q

What is the treatment for diverticulitis?

A

clear liquid diet

Ciprfloxacin or Bactrim + Metronidazole

244
Q

What is the treatment for diverticula?

A

high fiber diet

bleeding: fluids, blood products, octreotide (to reduce bleeding?)

245
Q

Ischemic colitis

A

MC type of bowel ischemia (vs mesenteric ischemia)

inflammation and injury of the large intestine d/t insufficient blood supply

246
Q

How is ischemic colitis dx?

A

CT most commonly used
colonoscopy, barium enema
heme + stool

247
Q

What is the treatment for ischemic colitis?

A

IV fluids, ABX, admit

248
Q

Mesenteric ischemia

A

DANGEROUS - 80% mortality rate
etiology: embolism, thrombosis or low flow states
embolism obstruction most commonly occurs in superior mesenteric artery

249
Q

What are risk factors for mesenteric ischemia?

A

old age, afib, atheroscleorsis

250
Q

How do pts with mesenteric ischemia present?

A

pain out of proportion to exam in the periumbilical region

251
Q

Hemo-concentration

A

increased HgB that is actually false

d/t dehydration or bleed?

252
Q

How is mesenteric ischemia dx?

253
Q

What is the treatment for mesenteric ischemia?

A

IVNS and immediate surgery consult

254
Q

What is the classic symptom of PVD?

A

peripheral vascular disease

intermittent claudication - reproducible pain in LE during exercise that is relieved with rest

255
Q

Hyperbilirubinemia

A

jaundice

typically presents in sclera first - around 2 - 2.5mg/dL

256
Q

Excess levels of Unconjugated vs conjugated bilirubin

A

unconjugated: hemolysis: increased production of bilirubin; or liver defect in the conjugation of bilirubin
conjugated: decreased excretion of conjugated bilirubin via intestinal tract

257
Q

Hepatitis A

A

RNA virus
fecal oral transmission
self limited
no chronic form or carrier state

258
Q

Hepatitis B

A

DNA virus
spread via IVdrugs or sex
incubation 1 - 6 months
10% develop chronic or carrier

259
Q

Hepatitis C

A 
DNA virus 
spread IV drugs 
incubation 2 weeks - 6 months 
Milder than HBV 
50% develop chronic
260
Q

Hepatitis D

A

can only replicate in the presence of HBV (acute or chornic)

261
Q

Hepatitis E

A

waterborne RNA virus endemic to Mexico, Asia, Africa

tends to cause fulminant hepatitis in pregnant women

262
Q

How do pts with hepatitis present?

A

jaundice, dark urine, pale stools
liver is usually enlarged and tender
=
icteric phase

263
Q

What labs can you expect for a pt with hepatitis?

A

AST and ALT >10x normal limit
elevations 2-3x with AST > ALT = alcohol-induced liver damage

Alk phos elevation = biliary obstruction or gallbladder dz

low serum albumin, glucose and prolonged PT

264
Q

What is the treatment for hepatitis?

A

IV fluids, antiemetic, VitK for elevated PT

prophylaxis for household and sexual partners for HepA/B pts

Hep C: sofosbuvir and simprevir

most pts can be treated outpt

265
Q

What is the treatment for alcoholic hepatitis?

A

fluids with D5W
thiamine 100mg w/ banana bag
correction of electrolytes (esp. Mg, K)

paracentesis for symptomatic ascites

266
Q

What is a hernia?

A

protrusion of a viscus through an opening into an abnormal location

267
Q

What are the different types of hernias?

A

Inguinal (75%): indirect are m/c –> bowel travels down a patent processes vaginalis into inguinal canal, can progress into scrotum
direct –> bowel protrudes through a defect in the abdominal wall in Hesselbach triangle
increase with age and physical exertion

Incisional (10%): occur at sites of previous abdominal surgery
Umbilical (5%): mostly in women
Femoral (5%): almost half of these become incarcerated or strangulated

268
Q

Infectious diarrhea is most commonly what?

A

70% - viral

24% - bacterial

6% - parasitic (think chronic diarrhea, travel hx, immunocompromised)

269
Q

Dysenteric vs nondysenteric pathogens causing diarrhea

A

nondysenteric: viral, s.aureus, b.cereus, ETEC, botulism, cholera, giardia
no mucus, no blood, no colon involvement, +/- fever

dysteteric: salmonella, shigella, campy, yersinia, C. diff
+mucus, + blood, + colon, + fever

270
Q

B. Cereus

A

Fried rice

271
Q

ETEC

A

travelers diarrhea

tx: supportive, cipro x 5 days

272
Q

Cholerae

A

rice water stools
gulf coast of texas and louisianna

single dose of cipro may shorten course

273
Q

Giardia

A

MC intestinal parasite in US

tx: metronidazole x 7 days

274
Q

Salmonella

A

dysentery
very common
treat sever illness or immunocompromised

Cipro x 7d

275
Q

Shigella

A

dysentery
very common, esp in kids

“sheets” of WBC in stool
tx: cipro x 3-5d

276
Q

Campylobacter

A

dysentery
backpackers diarrhea

tx: cipro for high risk pts

277
Q

Which dysentery infection mimics appendicitis?

A

yersinia

tx: cipro for at risk pts

278
Q

EHEC

A

grossly bloody diarrhea that mimic GI bleed or mesenteric ischemia
ABX will increase risk of complications

279
Q

C. Diff

A

dysentery

hx of clindamycin, PCN, or cephalopsorin use

tx: metronidazole or vancomycin x 14 days

280
Q

Entamoeba histolytica

A

dysentery

may develop hepatic abscess

tx: metro x 10 days followed by iodoquinol x 20 days

281
Q

What are the different antiemetics used in the ED?

A

prochlorperazine (compazine): 5-10mg IV in adults
odansetron (zofran): 4-8mg IV adults
Promethazine (phenergan): 12.5-25mg IV (use with caution in elderly, can lead to AMS)
Metoclopramide (Reglan): 5-10mg IV in adults

282
Q

What is the risk of using antidiarrheals?

A

such as loperamide (imodium), bismuth (pepto-bismol)

risk of toxic megacolon or colitis

283
Q

What is the most common GI complaint in the US?

A

constipation

acute is much more concerning than chronic (but don’t get anchored just because they have a hx of constipation)

284
Q

What is the work up for someone with constipation?

A

CBC (r/o anemia)
thyroid panel (r/o hypothyroid or hyperparathyroid)
CMP (r/o electrolyte issues - hypokalemia, hypercalcemia)
abdominal xray - obstruction

285
Q

What are the treatment options for chronic constipation?

A

milk of magnesia
mag citrate
lactulose
sorbitol

286
Q

What is the most common cause of cirrhosis?

A

chronic viral hepatitis

alcoholism

287
Q

How to pts with cirrhosis present?

A

typically in the ED d/t worsening ascites or edema or bleeds or encephalopathy

common s/s: anorexia, muscle loss, fatigue, n/v, ascites, low grade fever

288
Q

What is the treatment for spontaneous bacterial peritonitis?

A

cefotaxime 2mg IV

289
Q

What fluids can you give a pt you suspect has encephalopathy?

290
Q

Ascariasis

A

parasitic infection that travels through bloodstream to lungs
cough, fever, hemoptysis, eosinophilia

tx: pyrantel pamoate

291
Q

Pinworm

A

intense pruritus around anus at night

tx: pyrantel pamoate

292
Q

Hookworm

A

chronic anemia, cough, fever, diarrhea, weakness, eosinophilia

tx: pyrantel pamoate

293
Q

Threadworm

A

rash, cough, dyspnea, PNA , bloody mucoid diarrhea

tx: thiabendazole

294
Q

Whipworm

A

anorexia, diarrhea, rectal prolapse in peds

tx: mebendazole

295
Q

Schistosomiasis

A

hepatosplenomegaly, ascites, liver failure

296
Q

Tapeworm

A

fish: MC - pernicious anemia
Beef
Pork

297
Q

Trypanosomiasis

A

can cause Chagas dz, CHF, myocarditis, megacolon

298
Q

What is the most common cause of vertigo?

A

BPPV

d/t canalithiasis in the semicircular canals

299
Q

How is BPPV dx?

A

dix-hallpike test

300
Q

How is BPPV tx:

A

Epley maneuver

301
Q

Blepharitis

A

inflammation of eyelid margin
d/t staph, chronic inflammation, lid gland dysfunction

tx: warm compresses + erythromycin cream

302
Q

Conjunctivitis

A

viral: adenovirus, coxsackievirus, enterovirus, herpesvirus
bacterial: staph, strep, gonorrhoaea
allergic

itching, tearing, redness, sensation of FB

303
Q

What is the tx for conjunctivitis?

A

erythromycin (length of eyelid every 6 hours)
alt: polymixin-trimethoprim
FQ (preferred for contact lens wearers)

304
Q

What is a blow out fx?

A

fx to orbital floor d/t trauma
tear drop sign on CT
decreased visual acuity, diplopia that is worse with upward gaze

tx: AVOID blowing nose, corticosteroids reduce edema, ABX (d/t sinus exposure to eye cavity)
surgery consult with ENT

305
Q

“Blood and thunder” fundus

A

hyphema

pooling of blood in the anterior chamber

photophobia + anisocoria

tx: emergency referral for associated ocular trauma
elevation of head to 30 degrees
bilateral patching

306
Q

Acute angle glaucoma

A

ocular ischemia/infarction d/t intraocular HTN d/t aqueous outflow obstruction

s/s: mid-dilated fixed pupil w/ sluggish light reflex, photophobia, HA, N
*HA in older pts could be first sign of glaucoma
tunnel vision, “steamy” cornea

307
Q

How is acute angle closure glaucoma dx?

A

applanation tonometry
(>21mmHg)
gonioscopy >40mmHg

308
Q

How is glaucoma tx?

A
  • Acetazolamide (first line) to decrease intraocular pressure by decreasing aqueous humor production
  • topical BB (timolol) to reduce IOP without affecting visual acuity
  • miotics/cholinergics (pilocarpine, carbachol) to induce papillary constriction
309
Q

AMD

A

age related macular degeneration

central portion of the retina degenerates – central vision loss

dry: atrophic
wet: neovascular or exudative

amsler grid given to dry AMD to monitor progression of dz

inhibit VEGF reduces neovascularization in wet AMD (bevacizumab)

310
Q

What is the treatment for wet macular degeneration?

A

reduce neovasularization by inhibiting VEGF with intravitreal anti-angiogenics like bevacizumab

311
Q

Optic Neuritis

A

acute inflammation and demyelination fo optic nerve

MS is MC cause (ethambutol tx for TB can also cause this)

loss of color vision
unilateral vision loss after a few days
pain with eye movement

tx: IV methylprednison followed by PO steriods

312
Q

What is the treatment for optic neuritis?

A

IV methylprednisone followed by PO steroids

313
Q

Papilledema

A

usually bilaterally optic nerve swelling secondary to increased ICP

HA, N/V, enlarged blind spot in vision (negative Marcus Gunn pupil 0 see in optic neuritis)

dx: swollen optic disc on fundoscopy
CT to r/o mass then LP to determine if increased CSF pressure

tx: diuretics (Acetazolamide to decrease prodcution of CSF and aaqueous humor)

314
Q

What medication decreases the production of aqueous humor and CSF?

A

acetazolamide

315
Q

Retinal detachment

A

separation of neurosensory retina from pigmented retinal epithelium; d/t vitreous contraction/liquification
s/s: painLESS monocular vision loss preced by floaters
dx: bedside US, indirect ophthalmoscopy
tx: emergent referral for surgical photocoagulation, cryotherapy, vitrectomy, scleral buckle insertion

316
Q

What is the treatment for retinal vein occlusion?

A

urgen intravitreal VEGF inhibitor

s/s: painLESS sudden monocular visual blurring

dx: dilated fundoscopy, retinal angiography

317
Q

What is the treatment for barotrauma?

A

open eustachian tube (chew gum, valsalva, yawn)
antihistamines (benadryl)
decongestantns (sudafed, mucinex)

318
Q

What is barotrauma?

A

abrupt onset of conductive HL

dizziness, tinnitus, vertigo, N/V, TM rupture

319
Q

Labyrinthitis

A

peripheral vertigo

dizzy, fluctuating hearing loss, N/V, tinnitus, malaise, nystagmus

320
Q

Mastoidisits

A

usually extension of AOM or AOE (s. pneumo, s. pyogens, s aureus)
fever, chills, erythema of mastoid process
post auricular pian
fluctuant mass

tx: ENT referral
admission
cefotaxime or ceftriaxone

321
Q

What is the treatment for mastoiditis?

A 
cefotaxime or ceftriazone 
ENT referral (inpt)
322
Q

PTA

A

peritonsillar abscess

occurs when acute pharyngitis or tonsillitis spreads to the surrounding tissue in the pharynx causing collection of pus

B - hemolytic strep

hot potato voice
odynophagia x 2-3d
trismus

+/- CT w/ contrast

Tx: I&D - refer to ENT
ABX: augmentin or clindamycin (PO)
Unasyn (amp-sulbactam) IV

323
Q

What is the treatment for PTA?

A 
augmentin or clindamycin PO 
IV unasyn (amp - silbactam)
324
Q

Dental abscess treatment

A

drainge with scalpel
PCN VK or clindamycin
augmentin for dental pain?

325
Q

Thumb print sign

A

epiglotitis

sudden onset fever, drooling, tripoding, tachypnea, stridor, toxic appearing
dx: lateral cervical x-ray

tx: Urgent ENT consult for airway management
heliox _ cefuroxime

326
Q

What is the treatment for epiglotitis?

A

Urgent ENT consult for airway management

heliox _ cefuroxime

327
Q

Anterior vs posterior epistaxis

A

anterior: Kiesselbach plexus
posterior: sphenopalatine artery (behind septum)

328
Q

What is the the treatment algorithm for epistaxis?

A

1) pinch nose fo 15-20min + afrin (vasoconstriction)
2) look for site of bleeding - cautery with silver nitrate
3) packing with rhinorocket
ABX - augmentin
F/U with ENT in 48hours

329
Q

Centor Criteria

A

used to determine if you need to screen and treat strep

tonsillar exudate
fever of hx of fever >38
tender anterior cervical lymphadenopahty
absence of cough

3+ = consider ABX

330
Q

What is the ABX treatment for strep?

A

PCN g single dose

alternatives: PCN V 250mg q6h x 10d
first and second gen cephalosporins
erythromycin

331
Q

Fe deficiency anemia

A

increase transferrin
increase TIBC
decrease ferritin (Fe stores)

332
Q

Pernicious anmeia

A

B12 deficiency

autoimmune destruction/loss of gastric parietal cells that secrete intrinsic factor –> leads to B12 deficiency

333
Q

Hypersegmented neutrophils

A

b12 deficiency - macrocytic anemia

334
Q

swimmers ear

A

otitis externa

MC is pseudomonas

S/S: ear pain, swelling of ear canal, purulent exudate

tx: otic drops - aminoglycosides or FQ

335
Q

Acute OM

A

MC in infants and children
s. peunoma, H. flu

amoxicillin if <2
watch and wait if >2

336
Q

Acute laryngitis

A

usually viral following URI
if bacterial: M. catarrhalis or H. flu
s/s: hoarseness

tx: vocal rest
bacterial: erythromycin or augmentin

337
Q

What causes tympanic membrane perforation?

A

rupture can occur for infection (AOM) or trauma

tx: avoid moisture, most resolve on their own

338
Q

Acute sinusitis

A

S. pneumo, H. flue, M catarrhalis, s aureus

TTP over affected sinus

complications: orbital cellulitis, osteomyelitis

tx: NSAIDs for pain + saline washes
if sxs >14 days tx: amoxicillin

339
Q

Sickle cell has what type of inheritence pattern?

A

autosomal recessive

340
Q

Howell - Jolly bodies

A

can be seen with sickle cell anemia

as well as nucleated RBCs and target cells

341
Q

What is the treatment for sickle cell anemia?

A

hydroxyurea
PCN daily until 6yo

blood transfussions

342
Q

AML vs ALL age distribution

A 
ALL = kids 3-7yo 
AML = adulthood
343
Q

S/S of leukemia

A

thrombocytopenia
neutropenia
lymphadenopathy and hepatsplenomegaly = ALL
Pancytopenia w/ blasts

Auer rods in AML for bone marrow biopsy

344
Q

Auer rods

345
Q

JAK2 mutation

A

diagnostic for polycythemia

+ high Hct >50%

346
Q

Tx for polycythemia

A

serial phlebotomy

hydoxyurea

347
Q

Epi of pilonidal cysts?

A

M > F
15-30

hair follicles become infected

I&D

348
Q

Pressure sore stages

A

1: non-blanching redness; skin intact
2: open ulcer
3: full thickness - visible subq fat
4: full thickness - exposed muscle or bone

349
Q

Dacyoadenitis

A

lacrimal gland disorder
usually sterile inflammation (infectious rare - G+)
S/S: tenderness, swelling
Tx: steroids; chronic condition is less responsive to steroids

350
Q

What is the plan for a pt who comes in with hematoma of the external ear that began 7 days ago?

A

referred to ENT/surgery

best time to I&D is within first 24 hours –> ENT consult if longer than 24 hours

351
Q

Hodgkin’s lymphoma

A

lymphocyte neoplasm
bimodal distribution 20s and > 50s

painless lymphadenopathy –upper body with contiguous spread
EtOH can cause lymph node pain
*mediastinal lymphadenopathy
B-sxs

Dx: excisional biopsy - Reed Sternberg Cells - owl-eye appearance

Tx: local radiation
+/- chemo depending on stage

352
Q

Reed Sternberg Cells

A

Hodgkin’s lymphoma

owl eye appearance on biopsy

353
Q

Painless lymphadenopathy or the upper body

A

Hodgkin’s lymphoma

mediastinal lymphadenopathy

354
Q

Non-Hodgkin’s lymphoma

A

lymphocyte neoplasm with diffuse B cells and T cells

peripheral lymph nodes MC

S/S: painless lymphadenopathy

tx: Rituximab?

355
Q

What is the distribution of non-hodgins lymphoma?

A

peripheral lymph node

356
Q

What is the most common cause of cellulitis?

357
Q

Whatis the treatment for Cellulitis?

A

Keflex PO outpt

IV Vanco inpt

358
Q

How is DM dx?

A

if 2 fast glucose (greater than 8 hours apart) are 126+
if hemoglobin A1C is 6.5%+
if any random glucose test is 200+

359
Q

What is the difference between SJS and TENS?

A 
SJS = <10% body surface area sloughing
TENs = >30% bsa sloughing

+Nikolsky sign

360
Q

Which drugs are known for causing SJS or TENs?

A 
SATAn 
sufla
allopurinol 
tetracyclines
anticonvulsants
NSAIDs
361
Q

What is the treatment for lice?

A

pediculosis

Nix (permethrin)
head: 10 minutes
body/pubic: 8-10h

PO ivermectin if refractory

362
Q

Scabies

A 
Type 4 hypersensitivity reaction 
mites transmitted via prolonged close skin to skin contact or fomites 
takes 3-6 weeks to develop sxs 
spares neck and face/scalp 
intense pruritis that is worse at night

dx: clinicla, skin scrappings, felt pen

tx: permethrin (nix) applied full body for 8-14hours
repeat in 7 days
treat family members and sexual contacts

may return to work/school after on tx for 24 hours

363
Q

How can you tell RSV from asthma or reactive airway disease?

A

RSV will not improve with albuterol tx

364
Q

Bronchioloitis

A

MC lower resp infection in pts <2 yo caused by RSV
rhinorrhea, cough, low grade fever, tachy
self limited, typically improves in 2-5 days

365
Q

What does the EKG of someone with pericardial effusion look like?

A

low voltage
electrical alternans
sinus tachy

366
Q

What is the treatment for an EKG with tachycardia, no P waves, and narrow QRS waves?

A

plus its an irregularly irregular rhythm
A. fib: rate control = diltiazem or metoprolol

if this was just tachycardia and not a.fib then the treatment would be adenosine
you can tell the different by whether or not the rhythm is regular

367
Q

What is the first line treatment for someone with aortic dissection?

A

Esmolol

we want to control the rate before we control the vasodilation to prevent reflex tachycardia and thus more shearing (nitroprusside)

368
Q

Type A vs Type B aortic dissections

A

Type A = ascending = immediate surgery

Type B = descending = medical management

369
Q

What medication is classically implicated in causing nephrogenic diabetes insipidus?

370
Q

Myxedema coma is seen with which thyroid condition?

A

hypothyroidism

371
Q

Osteomyelitis in children is dx how?

A

MC sxs: fever + joint pain

elevated ESR and CRP are 98% sensitive for osteomyelitis in peds

gold standard: bone biopsy + culture

xray: periosteal elevation or bony erosions

372
Q

What are the back pain red flags?

A

weight loss, night pain (tumor)
fever, chills, sweats (infection)
acute bony tenderness (fracture)
morning stiffness >30min in young pt (seronegative spondyloarthropathy)

373
Q

Steeple sign

A

croup

subglottic tracheal narrowing

374
Q

Testicular torsion

A

young male with intense scrotal pain
no cremasteric reflex
dx: doppler US

375
Q

“Machine-like” murmur

A

PDA
pulmonary artery to descending aorta
bounding pulse
poor feeding

tx: IV indomethacin

this is why pregnant pts can NOT take NSAIDs –> premature closure of PDA

376
Q

What is a common side effect of lithium?

A

nephrogenic diabetes insipidus

377
Q

Horner’s Syndrome

A

ptosis, miosis, anhydrosis

seen in cluster HA - unilateral
nasal congestion, lacrimation, conjunctivitis

378
Q

What is the first line treatment for cluster HA?

A

100% oxygen

prophylaxis: verapamil

379
Q

What is the treatment for migraines?

A

MC in women

triptans or ergotamines (5HT1 agonists) 
DA antagonist (compazine, metoclopramde)

toradol 30mg IV

380
Q

What is the most common type of HA overall?

A

tension HA

381
Q

Middle meningeal artery bleed?

A

epidural hematoma

lucid interval

balloon shape on CT - does not cross suture lines

382
Q

Tearing of the bridging veins

A

subdural hematoma
crescent moon shaped - crosses suture lines

neurologic emergency - surgical intervention to decrease ICP
surgery within 2-4h

383
Q

Status epilepticus treatment

A

Lowestein algorithm
lorazepam 2mg IV (or diazepam)
Phenytoin 20mg/kg IV
Phenobarbital

384
Q

What is the treatment for Bell’s Palsy?

A

UNABLE to raise eye brows

prednisone 60-80mg/day x 1 week + patching of eye
+/- acyclovir

385
Q

What is the treatment for Guilain Barre?

A

IVIg or plasmaphoresis

diminished deep tendon reflexes

386
Q

Where does scabies avoid?

A

neck and face

387
Q

What is the treatment for impetigo?

A

topical mupirocin (bactroban)

388
Q

What is the most common type of kidney stone?

A

calcium oxalate or calcium phosphate

389
Q

What is the treatment for epididymitis for a pt <30 yo?

A

assume STD related

ceftriaxone 250mg IM + doxycycline 100mg BID x 10 days

390
Q

What is the treatment for epididymitis for a pt >30 yo?

A

Bactrim 160/800mg or cipro 500mg BID x 10-14d

391
Q

What is the treatment for nephrolithiasis?

A

IV hydration
NSAIDs (tordol?)
zofran
ceftriazone if infx

392
Q

What is the treatment of cellulitis?

A

outpt: keflex PO
inpt: IV vanco

393
Q

What is the treatment for prostatisis?

A

tender boggy prostate

> 35yo: FQ or bactrim x 4-6 weeks
<35yo: ceftraixone, or doxycycline, or oflaxacin

394
Q

Orchitis

A

occurs only if post-pubertal pts
usually associated with systemic infection - mumps esp
Tx: bed rest, heat application, oral analgesia

395
Q

When are urine cultures ordered for poss cystitis?

A

immunocompromised
suspected pyelonephritis
indwelling catheters

396
Q

What is the treatment for cystitis?

A

UA (>/= 10 leuks)

Nitrofurantoin 100mg PO BID x 5d
bactrim or ciprofloxacin alternatives

pregnancy: nitrofurantoin or amoxicillin

Men: consider STD treatment (250 ceftriaxone + 1g azithromycin)

397
Q

What is the treatment for pyelonephritis?

A

use urine culture and susceptibility test

levofloxacin, cipro, bactrim, amoxicillin

398
Q

BUN:Cr >20:1

A

Pre-renal AKI

399
Q

BUN:Cr <10:1

A

post-reanl AKI

400
Q

What is the treatment for AKI?

A

if acidosis, hyperkalemia or volume overload: dialysis

treat underlying causes:

prerenal: five fluids
postrenal: foley to eliminate obstruction

401
Q

What is the treatment for corneal ulcer?

A

topical ciprofloxacin

covering psudomonas

402
Q

What is the treatment for PID for inpt?

A

cefotetan or cefoxitin IV + doxy IV

inpt:
ill-appearing (septic)
pregnant
tubo-ovarian abscess

403
Q

Bones, stones, groans, psych overtones

A

hypercalcemia

MC d/t maligancy or primary hyperparathyroidism

groans: abdominal pain (N, cramping, constipation)

404
Q

MAT

A

mutlifocal atrial tachycarida
irregular rhythm with P waves –at least 2 different P waves

etiology: COPD, hypoxia, pulmonary HTN

405
Q

What is the most sensitive finding of cauda equina?

A

urinary retention (100-200ml post void residual volume)

lumbarsacral nerve root compression

eti: herniated disk

dx: MRI
tx: surgical decompression

406
Q

Leading cause of sudden cardiac death in young athletes?

A

hypetrophic cardiomyopathy

407
Q

What is the MC cardiomyopathy?

A

dilated

idopathic
familial pattern, EtOH, meds (chemo), infections, postpartum

408
Q

What is the treatment of pertussis?

A

Macrolides (azithromycin, clarithromycin, erythromycin) or bactrim

409
Q

Which ABX are contrainidcated in pts with G6PD deficiency?

A

sufla drugs like bactrim

410
Q

What are the components of the Ranson criteria?

A

acute pancreatitis
at admission:

age >55yo 
WBCs >16,000 
Blood glucose >200
LDH >350 
AST >250
411
Q

What does the LP for a pt with Guillain-Barre show?

A

elevated proteins

few cells

412
Q

What is the first line treatment for trigeminal nueralgia?

A

carbamazepine 100mg BID

alt: gabapentin

413
Q

Parkland formula

A

used in 2nd-4th degree burns to determine how much fluid resuscitation to give in first 24 hours

(4x weight in kg) x (TBSA of 2nd-4th degree burns)
first 50% given in first 8 hours

414
Q

What is the leading cause of sudden cardiac death in young athletes?

A

hypertrophic cardiomyopathy

415
Q

What is the treatment for H. pylori infection?

A

triple therapy CAP

clarithromycin, amoxicillin (or metro), PPI

416
Q

Butterfly rash on the face

A

erisipelas
well demarcated (unlike celluitis)
prodrome: fever, chills, malaise

tx: amoxicillin

butterfly rash is also seen with Lupus (malar rash)

417
Q

Optic neuritis

A

MC in MS pts
loss of color vision in one eye
pain with eye movement

tx: IV steroids (methylprednisone)

418
Q

What is the name for an intra-articular fracture at the base of the thumb metacarpal with associated dislocation or subluxation at the carpometacarpal joint?

A

Bennett fx

419
Q

What is the treatment for absence seizures?

A

Ethosuximide first line

420
Q

What is the treatment for Lyme disease?

A

doxycycline

pedis/pregnant: amoxicillin 14d

421
Q

Smudge cells

422
Q

What is the treatment for myasthenia gravis?

A

Acetylcholinesterase inhibitors
pyridostigmine or neostigmine

IVIG or plasmapheresis for rapid response

423
Q

What is the treatment for Parkinson’s?

A

Levodopa/Carbidopa

dz:
lewy bodies at substantia nigra
depletion of dopamine

424
Q

Charcot’s Neuro Triad

A

seen with MS

Nystagmus, Staccato speech, Intentional tremor

425
Q

What is the first line treatment for acute exacerbations of MS?

A

IV steroids

B-interferon or glatiramer acetate for replasing remitting

426
Q

What is the treatment for Meningitis?

A

Ceftraixone and vanc +/- ampicillin if elderly

427
Q

What is the treatment for pemphigus?

A

Either pemphigus vulgaris or vullous pemphigoid, the treatment is steroids x 5-10 weeks

recall that PV is found in the mucosa and has + Nikolsky sign

while Bp is more old people boils that does not have + Nikolsky sign

428
Q

SIRS cirteria

A

HR >90
RR >20 or PaCO2 <32
WBC >12,000 or <4,000 or >10% bandemia
Temp >38 or <36

429
Q

Free water deficit

A

Used in pts with hypernatremia

0.6(kg)x(((Na+)-145)/145)

ER EOR (1 decks)

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