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Emergency Medicine > Exam 2 > Flashcards

Exam 2 Flashcards

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1
Q

What is psuedohyponatermia & causes?

A

Serum level dec. but total body sodium normal

Severe

  1. Hyperglycemia
  2. Hyperproteinemia
  3. Hyperlipidemia
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2
Q

S/S Hyponatremia

A

<113 - seizures & coma

High mortality w/ CNS findings

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3
Q

Dx hyponatermia

A

True hyponatremia - osmolality dec

Factitious hyponatremia - osmolality normal or inc.

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4
Q

Hypertonic hyponatermia

A

Osmotic pressure >295

MCC hyperglycemia
Each 100mg/dL inc. in glc dec. serum sodium by 1.7 due to water moving into ECF

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5
Q

Isotonic hyponatremia

A

Osmotic pressure 275-295

High proteins & lipids cause a lab to report a falsely lowered sodium than what the serum actually contains

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6
Q

Hypotonic hyponatremia

A

Osmotic pressure >275

Hypovolemic - loss of Na & water
Euvolemic - normal volume status
Hypervolemic - excess total body water

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7
Q

Causes of renal losses of sodium

A

Hypovolemic hyponatremia
Urinary sodium >20

  1. Diuretics
  2. Renal tubular acidosis, chronic renal failure, nephritis
  3. Osmotic diuresis
  4. Addison’s
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8
Q

Causes of extrarenal losses of sodium

A

Hypovolemic hyponatremia
Urinary sodium <20

  1. Vol replacement w/ hypotonic fluids
  2. GI loss (V/D, tube suction)
  3. 3rd space loss (burns, peritonitis, pancreatitis)
  4. Sweating (CF)
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9
Q

Euvolemic hyponatremia

A

Urinary sodium >20

  1. SIADH - tumors, CNS disease, pulm disease, meds, idiopathic
  2. Hypothyroid
  3. Pain, stress, psychosis - stimulates ADH
  4. Drugs - carbamazepine, phenothiazines, TCAs
  5. Water intoxication
  6. Glucocorticoid deficiency
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10
Q

Hypervolemic hyponatremia

A

Volume overload

Urinary sodium >20 - renal failure

Urinary sodium <20 - CHF, cirrhosis, nephrotic syndrome

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11
Q

Tx hyponatremia

A

Hypervolemic or euvolemic hyponatremia - fluid restriction

SIADH - demeclocycline or furosemide

Hypovolemic hyponatremia - isotonic saline

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12
Q

What can happen if you correct hyponatremia too rapidly?

A

Central pontine myelinolysis brain injury

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13
Q

Acute Hyponatremia <120 w/ CNS Sx - how do you treat?

A

Give 3% hypertonic saline at 25-60 mL/hr

Do not raise Na >2mEq/L/hr

Stop when sodium reaches 120 or when Pt improves

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14
Q

Tx chronic hyponatremia

A

Correction of Na no more than 0.5 mEq/L/hr

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15
Q

When do you admit hyponatremia Pts?

A
  1. Na <125
  2. Require IV
  3. Significant comorbidities
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16
Q

Hypernatremia causes

A

Na >150

  1. Reduced water intake
  2. Inc. water loss - hypervent., DI, osmotic diuresis, thyrotoxicosis, severe burns
  3. Inc. sodium intake/renal salt retention - hypertonic saline ingestion, sodium bicarb, hyperaldosteronism, Cushing’s
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17
Q

Sx hypernatremia

A

Usually at Na>158 - rate of change important

  1. Confusion, weakness, irritable, restless, tremulous, seizures, coma
  2. Hypocalcemia may be present causing CNS Sx
  3. Flat neck veins, orthostatic HOTN, tachycardia, poor skin turgor, dry mucous membranes
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18
Q

Tx hypernatremia

A

Severe dehydration - NS or LR
Then 0.45% saline

Sodium reduction should not exceed 15mEq/L/day
Reach normal serum sodium in 48-72hrs

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19
Q

You lose 1L of water, how much does your serum sodium increase?

A

3-5

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20
Q

What is the MC electrolyte abnormality?

A

Hypokalemia - <3.5

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21
Q

Causes of hypokalemia

A
  1. Extrarenal - inadequate intake, V/D, inc. insulin, alkalosis
  2. Renal - diuretics, aldosteronism, renal tubular acidosis
  3. Lithium, heavy exercise, heat stroke, fever
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22
Q

S/S hypokalemia

A
  1. Weakness, paresthesias, polyuria, orthostatic HOTN, areflexia, ileus, arrhythmias
  2. EKG - T wave flattening/inversion, U waves, ST depression, PVC’s, wide QRS, tachyarrhythmias

Want to get CK, Mg, UA, BMP

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23
Q

Tx hypokalemia

A

K>2.5 w/o EKG findings - oral replacement daily until normal

K<2.5

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24
Q

Hyperkalemia causes

A

K >5.5

  1. Factitious - release of intracellular K by hemolysis during phlebotomy
  2. Extrarenal causes - insulin deficiency, acidosis, hyperosmolality, beta-blockers, supplements, massive transfusion, crush injuries, burns, mesenteric or muscle infarction
  3. Renal causes - chronic renal insufficiency, acute renal failure, hypoaldosteronism, drugs (NSAIDs, ACEi, K-sparing diuretics)
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25
Q

S/S hyperkalemia

A

Weakness, paresthesias, confusion, paralysis, areflexia, V/D, ileus, arrhythmias (VF, heart block, asystole)

EKG changes
6.5-7.5 - Prolonged PR, tall peaked T waves, short QT
7.5-8 - Flattening of P wave, QRS widening
10-12 - QRS complex degradation into a sinusoidal pattern

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26
Q

Tx hyperkalemia

A
  1. Albuterol
  2. CaCl or gluconate
  3. Sodium bicarb
  4. Insulin & glc
  5. Furosemide
  6. Dialysis
  7. Kayexalate
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27
Q

Causes of hypocalcemia

A

Ionized Ca <8.5

  1. Shock, sepsis
  2. Renal failure
  3. Pancreatitis
  4. Hypomagnesemia, alkalosis, phosphate overload, dec. albumin
  5. Hypoparathyroidism
  6. Malabsorption
  7. Meds - phosphate lax, phenytoin, phenobarbital, theophylline, loop diuretics, glucocorticoids
  8. Parathyroidectomy
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28
Q

S/S hypocalcemia

A
  1. Circumoral & distal extremity paresthesis
  2. Irritability, weakness, fatigue, muscle cramps
  3. Seizures
  4. Hyperreflexia
  5. Carpopedal spasm, tetany, laryngospasm
  6. Trousseau’s sign
  7. Chvostek’s sign
  8. Prolonged QT
  9. Sinus bradycardia
  10. Heart block
  11. VT/VF
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29
Q

Tx hypocalecemia

A

Asymptomatic - oral therapy
Tx hypomagnesemia

<1.3 or Sx - IV Cagluconate over 10 min then maintenance infusion
-careful w/ Digoxin

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30
Q

Hypercalcemia Causes

A

Total Ca > 10.5
Ionized Ca >2.7

  1. CA/hyperparathyroidism**
  2. Endocrine - hyperthyroidism, pheochromocytoma, adrenal insufficiency
  3. Granulomatous disorders - sarcoid, TB, histoplasmosis, coccidiomycosis
  4. Immobilization, Paget’s disease, dehydration, excess Ca ingestion, milk alkali syndrome
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31
Q

S/S hypercalcemia

A
  1. Weakness, depression, confusion, lethargy, personality changes, N/V, anorexia, constipation, HA, abd pain
  2. Dehydation, dec. motor strength
  3. Dec. mental status
  4. Ataxia, hyporeflexia
  5. Fx
  6. HTN, wt loss, renal insufficiency, cardiac arrest
  7. Short QT, widened T waves, bradyarrhythmias, BBB, AV blocks

Stones, bones, moans & groans

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32
Q

Tx hypercalcemia

A

Any Sx Pt or total Ca >14

  1. Vol replacement
  2. Furosemide
  3. Mithramycin
  4. Pamidronate
  5. Calcitonin
  6. Hydrocortisone
  7. Dialysis

Watch hypokalemia & hypomagnesemia

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33
Q

Causes of hypomagnesemia

A

<1

  1. Alcoholism
  2. Malnutrition
  3. Cirrhosis
  4. Pancreatitis
  5. Excessive GI fluid losses (Diarrhea)
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34
Q

S/S hypomagnesemia

A
  1. Malaise
  2. Muscle weakness
  3. Anorexia, N/V
  4. Seizures
  5. Chvostek & Trousseau’s
  6. Tremors, twitching, clonus, dec. DTR, carpopedal spasm, tetany, delirium, dysarthria
  7. Tachyarrhythmias, Torsades, prolonged PR & QT
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35
Q

Tx hypomagnesemia

A

Mild - Mg(OH)2

Severe - neuro findings & arrythmias - MgSO4

Admit if <1 & Sx

Watch hypokalemia, hypocalcemia, hypophosphatemia

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36
Q

Hypermagnesemia Causes

A

> 2.5 - Rare - usually w/ renal failure/iatrogenic cause

  1. Rhabdo
  2. Tumor lysis
  3. Burns
  4. Trauma
  5. DKA
  6. Hypothyroid
  7. Antacids
  8. Laxative abuse
    9;. Eclampsia Tx
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37
Q

S/S hypermagnesemia

A

Nonspecific

  1. N/V
  2. Lethargy, confusion
  3. Coma
  4. If >4 - Dec. DTR’s, muscle weakness, bulbar paralysis, resp. insufficiency
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38
Q

Tx hypermagnesemia

A
  1. Cagluconate/chloride
  2. Furosemide
  3. Dialysis

Watch hyperkalemia/hypercalcemia

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39
Q

Causes of resp. acidosis

A
  1. CNS lesions
  2. Sedative therapy & overdose
  3. Neuromuscular disorders
  4. Pleural disease
  5. COPD
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40
Q

Causes of resp. alkalosis

A
  1. Anxiety - MCC
  2. Hypoxia
  3. Pulm. disorders
  4. Salicylate toxicity
  5. CNS disorders
  6. Pregnancy
  7. Early sepsis
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41
Q

At what pH is there dec. cardiac function?

A

> 7.73

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42
Q

Causes of anion gap metabolic acidosis

A 
Alcohol
Methanol
Uremia
DKA
Paraldehyde
Iron, Isoniazied
Lactic acidosis
Ethylene glycol
Carbon monoxide
Aspirin
Toluene
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43
Q

What is the MCC of anion gap met. acidosis?

A

Lactic acidosis - due to dec. oxygen to tissues, sepsis, shock

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44
Q

Causes of nonanion gap metabolic acidosis

A
  1. Conditions that cause renal loss of bicarb - renal tubular acidosis, acetazolamide therapy
  2. Conditions that lead to GI loss of bicarb - diarrhea, pancreatic fistula, ureterosigmoidostomy
  3. HCl, ammonium chloride, oral CaCl2
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45
Q

S/S met. acidosis

A

pH s respiration - rapid regular deep resp. rate

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46
Q

Anion gap formula

A

Na - (HCO3 - Cl)

Normal is 10-12

> 12 - met. acidosis

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47
Q

S/S met. alkalosis

A
  1. Tetany
  2. Seizures
  3. Loss of Ca, K & Mg
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48
Q

MCC hypoglycemia?

A

Insulin

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49
Q

Causes of hypoglycemia

A
  1. Inadequate food intake
  2. Insulin/meds
  3. Drug interaction
  4. Infection
  5. Renal/hepatic failure
  6. ACS
  7. Stress
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50
Q

Tx hypoglycemia

A
  1. Glucose D50W
  2. Glucagon
  3. Octreotide - suppresses insulin secretion

If alcoholic - give thiamin to prevent Wernicke-Korsakoff’s syndrome

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51
Q

Tx hypoglycemia cause by sulfonylurea?

A

Octreotide

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52
Q

Causes of DKA

A
  1. Not taking insulin
  2. Infection
  3. Pregnancy
  4. Hyperthyroidism
  5. Substance abuse (Cocaine)
  6. Meds - steroids, thiazides, antipsychotics, sympathomimetics
  7. Heat-related illness
  8. CVA
  9. GI hemorrhage
  10. MI
  11. PE
  12. Pancreatitis
  13. Major trauma/surgery
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53
Q

S/S DKA & HHS

A
  1. N/V, abd pain
  2. Polyuria, polydipsia
  3. AMS
  4. Kussmaul’s breathing
  5. Fruity breath
  6. Dehydration - HOTN, tachycardia, dry skin, dry mucous membranes
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54
Q

Labs DKA

A
  1. Glc >250
  2. Anion gap >10
  3. Bicarb <7.3
  4. Ketonemia
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55
Q

Tx DKA

A
  1. NS
  2. Follow K+
  3. Insulin - 0.1/kg/hr
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56
Q

Causes of hyperosmolar hyperglycemia state

A

Diabetics

  1. Stressor - infection, CVA, GI bleed, MI, pancreatitis
  2. Meds - thiazide diuretics, corticosteroids, lithium, beta-blockers, Ca-channel blockers, phenytoin

Nondiabetics
1. Severe dehydration/excess glucose load - burns, heat stroke, dialysis, diet, hyperalimentation

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57
Q

Dx HHS

A
  1. Glc >600
  2. Osmolality >315
  3. Bicarb >15
  4. pH >7. 3
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58
Q

HHS Tx

A
  1. IVF - correct 1/2 w/in 1st 12h then rest over next 24h
  2. Once HOTN, tachycardia & urine output improve - switch to 0.45% NS
  3. Potassium
  4. Insulin
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59
Q

Who gets alcoholic ketoacidosis?

A

Alcoholics who abruptly stop drinking after a binge

or 1st time drinkers

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60
Q

S/S alcoholic ketoacidosis

A

Binge drinking then

  1. Abd pain - pancreatitis, gastritis, hepatitis
  2. N/V
  3. Alcohol withdrawal/DTs
  4. Dehydration - HOTN, tachycardia
  5. Kussmaul’s respiration
  6. +/- fever
  7. NL MS/coma
  8. Abd tenderness
  9. Heme + stool
  10. Hepatomegaly
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61
Q

Dx alcoholic ketoacidosis

A
  1. Low/NL/slightly inc. glc
  2. Wide anion gap met. acidosis
  3. +serum ketones
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62
Q

Tx alcoholic ketoacidosis

A
  1. Saline w/ glucose & thiamin
  2. Insulin if DM
  3. Consider Mg & multivitamin
  4. Bicarb if pH<7.1
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63
Q

Type D lactic acidosis

A

Shortened bowel sundrome caused by bacterial fermentation

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64
Q

Type A lactic acidosis

A

Caused by tissue hypoxia
Has a high mortality

Related to hemorrhagic, hypovolemic, cardiogenic & septic shock

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65
Q

Type B lactic acidosis

A

No tissue hypoxia - may be abrupt in onset or over a few hours

Seen w/ DM, liver disease, seizures, renal disease, genetic disorders of metabolism, drugs (ethanol, metformin, salicylate ingestion)

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66
Q

S/S lactic acidosis

A

Produces anion gap acidosis

Abrupt onset - ill Pt

  1. Hypoventilation or Kussmaul’s breathing
  2. Lethargy, coma
  3. Vomiting, abd pain
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67
Q

Tx lactic acidosis

A
  1. Ventilation & volume replacement
  2. Diuresis
  3. Bicarb if pH<7.2

Admit to ICU

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68
Q

Causes of thyroid storm

A
  1. Infection - MCC
  2. Trauma, surgery, hyperosmolar coma
  3. DKA
  4. Withdrawal of thyroid med, iodine or contrast administration, thyroid gland palpation, ingestion of thyroid hormone, amiodarone, large doses of povidone-iodine w/ skin breakdown
  5. MI, CVA, PE
  6. Parturition (childbirth), eclampsia
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69
Q

S/S thyroid storm

A
  1. Exopthalmos
  2. Widened pulse pressure
  3. +/- Palpable goiter
  4. Heat intolerance
  5. Fever
  6. Tachycardia out of proportion to fever
  7. Profuse sweating
  8. Dehydration
  9. Hair loss
  10. Inc. SBP
  11. Inc. pulse pressure
  12. Systolic flow murmur
  13. Sinus tachycardia
  14. AFib, CHF, pulm. edema
  15. Agitation, restlessness, psychosis, confusion, obtundation, coma, proximal muscle weakness, hyperreflexia
  16. Wt loss, N/V/D, anorexia, abd pain
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70
Q

Dx thyroid storm

A
  1. Inc. FT4
  2. Suppressed unmeasureable TSH
  3. Sinus tach/AFib
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71
Q

Tx thyroid storm

A
  1. IVF w/ dextrose
  2. Oxygen
  3. Acetaminophen
  4. Cooling blankets
  5. Cholestyramine
  6. Propylthiouracil/Methimazole
  7. Iodine, KI, NaI, Li
  8. Propranolol
  9. Hydrocortisone
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72
Q

Causes of myxedema coma

A

Infection, cold, trauma, MI, CHF, CVA, GI bleed, surgery, burns
Meds - beta-blockers, sedatives, narcotics, amiodarone
MC in winter months in old ladies

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73
Q

S/S myxedema coma

A
  1. Hypothermia
  2. Resp distress w/ hypoventilation, hypercapnia, hypoxia
  3. Cardiomegaly, vent arrhythmias, HOTN, bradycardia
  4. Seizures, ataxia, tremors, slow mentation, delusions, psychosis
  5. Megacolon, urinary retention, abd distention
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74
Q

Dx myxedema coma

A
  1. High TSH
  2. Low T4
  3. Dec. Na & Cl
  4. Hypoxia & hypercapnea
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75
Q

Tx myxedema coma

A

Tx before labs confirm

Thyroid replacement therapy
Supportive care

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76
Q

S/S adrenal crisis

A
  1. HOTN refractory to fluids & pressors
  2. Dehydation
  3. Weakness, lethargy
  4. Shock
  5. Delirium
  6. Abd pain w/ N/V
  7. +/- sepsis
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77
Q

Dx adrenal crisis

A
  1. Hyponatremia
  2. Hypoglycemia
  3. Hypercalcemia
  4. Inc. BUN
  5. Mild met. acidosis
  6. Flattened T waves, Prolonged QT & PR, low voltage, ST depression, signs of hypo/hyperkalemia
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78
Q

Tx adrenal crisis

A
  1. IVF
  2. Hydrocortisone
  3. Vasopressors
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79
Q

Cause of Wernicke-Korsakoff’s syndrome

A

Alcoholic w/ poor nutrition from thiamin deficiency

PPTd by giving glucose to alcoholic w/ inadequate thiamin

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80
Q

S/S Wernicke-Korsakoff

A

Triad

  1. AMS
  2. Opthalmoplegia
  3. Gait ataxia

Also

  1. Hypothermia
  2. HOTN
  3. Coma
  4. Circulatory collapse
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81
Q

Dx Wernicke-Korsakoff

A

Usually made clinically

Tx immediately

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82
Q

Tx Wernicke-Korsakoffs

A
  1. Thiamin

2. Mg

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83
Q

What is Cullen’s sign & when is it seen?

A

Ecchymosis of umbilicus

From retroparitoneal hemorrhage from pancreatitis or trauma

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84
Q

What is Turner’s sign & when is it seen?

A

Flank ecchymosis

From retroperitoneal hemorrhage from pancreatitis or trauma

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85
Q

What is caput medusae & when is it seen?

A

Dilated veins around umbilicus

Seen in liver disease

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86
Q

Tympanic abdomen percussion means??

A

Dilated bowel loops

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87
Q

Pt comes in w/ CP, given NTG & gets better. What was wrong?

A

Could be cardiac or esophageal…needs more testing

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88
Q

Tx esophageal food bolus

A
  1. Carbonation - EZ gas
  2. IV glucagon - smooth muscle relaxer
  3. Acute endoscopy
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89
Q

MCC esophageal perforation?

A

Iatrogenic

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90
Q

What is Hamman crunch & when is it seen?

A

Heard on heart ascultation

Due to mediastinal emphysema

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91
Q

S/S esophageal perforation

A
  1. Pain acute, severe, diffuse, located in chest, neck, abd w/ radiation to back/shoulders
  2. Pain worse w/ swallowing
  3. HOTN
  4. Fever
  5. Abd rigidity
  6. Tachycardia, tachypnea

CXR - mediastinal air, SQ emphysema, wide mediastinum, effusion

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92
Q

Dx & Tx esophageal perforation

A
  1. Chest CT/endoscopy

Tx

  1. Shock resuscitation
  2. IV abx
  3. Surg. consult
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93
Q

S/S swallowed FB in kiddos

A
  1. Refusal to eat
  2. Inc. salivation
  3. Odynophagia
  4. Vomiting
  5. Choking
  6. Resp. Sx - stridor, cough, wheeze
  7. Neck or throat pain
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94
Q

Tx FB swallow

A

Distal to pylorus - d/c & wait to pass

Obstruction? Emergent ednoscopy
-button batters, perf, coin at cricopharyngeus muscle, >24h

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95
Q

Swallowed button battery…what do you do??

A

Can cause corrosion & perf…get Xray
If above pylorus - endoscopy
If passed - watch & f/u in 24h, repeat films in 48h

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96
Q

Tx body packers

A

Observe or whole bowel irrigation

Endoscopy contraindicated - can rupture!

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97
Q

PUD Dx & Tx

A
  1. CXR - free air in 75%
  2. +/- CT

Tx

  1. Labs - type & cross
  2. 2 large bore IVs
  3. O2
  4. NG tube
  5. Broad spectrum abx
  6. Surg. consult
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98
Q

MCC Upper GI bleed?

A

PUD

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99
Q

Causes of upper GI bleeds

A
  1. PUD - epigastric pain, melena/hematemesis, stool +
  2. Variceal bleeding - painless, massive hematemesis, signs of chronic liver disease
  3. Mallory-weiss tear - Hx of forceful vomiting
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100
Q

Tx upper GI bleed

A
  1. 2 large bore IVs
  2. Transfusion of PRBCs
  3. PUD? IV PPI/H2 blocker
  4. +/- vasopressin
  5. Mallory weiss tear? d/c after bleeding stops
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101
Q

MCC N/V?

A

Viral gastroenteritis

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102
Q

What is dysentery diarrhea?

A

Contains blood, mucus & pus

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103
Q

What is gastroenteritis?

A

Acute intestinal inflammation causing diarrhea w/ N/V

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104
Q

What should you suspect if you see systemic illness, fever & bloody stools?

A
  1. Salmonella
  2. Shigella
  3. Campylobacter
  4. Toxin producing E. coli
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105
Q

What is a BRAT diet & who should use it?

A

Bananas
Rice
Apple sauce
Toast

diarrhea Pts

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106
Q

When should you avoid antidiarrheals?

A

ex. Loperamide

Don’t use w/ toxigenic gastroenteritis

  1. Toxin producing E. coli
  2. Staph aureus
  3. Bacillus cereus
  4. C. diff
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107
Q

S/S diarrhea caused by abx or other meds

A

No cramps, fever or fecal leukocytes

Diarrhea goes away after meds stopped

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108
Q

MCC infectious diarrhea

A

Virus

Norovirus

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109
Q

Which abx is most often assoc. w/ C. diff?

A

Clindamycin

also cephalosporings, PCN & fluoroquinolone

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110
Q

Dx & Tx C. diff

A

C. diff toxin in stool
Colonoscopy? Yellowish plaques in lumen

Mild - monitor

Moderate - Flagyl for 10-14 days

Severe - hospitalize, Vanco PO x 10days

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111
Q

What is tenesmus?

A

Feeling like you have to poop but your bowels are empty

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112
Q

Dx & Tx Crohn’s & ulcerative colitis

A

CT

  1. Restore fluids & electrolytes
  2. NPO
  3. NG suction for obstruction, ileus, toxic megacolon
  4. Narcotics
  5. Abx
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113
Q

Causes of toxic megacolon

A
  1. Antidiarrheals
  2. Hypokalemia
  3. Narcotics
  4. Cathartics
  5. Pregnancy
  6. Enemas
  7. Recent colonoscopy

Ulcerative colitis & Crohn’s at inc. risk

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114
Q

MCC small bowel obstruction??

A

Adhesions from abdominal surgery

2nd MCC? Incarceration of groin hernia

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115
Q

MCC large bowel obstruction?

A

CA

2nd MCC? Diverticulitis

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116
Q

Dx bowel obstruction

A

Abd CT w/ contrast
Xray - air fluid levels

WBC >20k - gangrene, intra-abd abscess, peritonitis
WBC >40k - mesenteric vasc. occlusion
Inc. Hct, BUN & Cr - vol. depletion & dehydration
Inc. urine spef. gravity, ketonuria, elevated lactate & met. acidosis - severe disease

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117
Q

Tx bowel obstruction

A
  1. Surg. consult
  2. NG tube if severe distention & vomiting
  3. IVF
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118
Q

Which types of bowel obstructions are surgical emergencies?

A
  1. Closed-loop obstruction
  2. Bowel necrosis
  3. Cecal volvulus
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119
Q

Tx adynamic ileus

A
  1. IVF

2. Observation

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120
Q

What is pseudo-obstruction?

A

aka Ogilvie syndrome
Distention of colon but no obstruction
Xray - dilated bowel w/o air fluid levels

Risk factors - age, anticholinergics/TCAs, recent surg.
Avoid barium studies

Tx - colonoscopy or neostigmine infusion

121
Q

Dx & Tx diverticulitis

A

Abd CT - inc. soft tissue density w/ pericolic fat, bowel wal lthickening

  1. Supportive - bowel rest & IVF
  2. Cipro & Flagyl
  3. Surgery if perforation, obstruction or abscess
122
Q

S/S diverticulitis

A
  1. LLQ pain
  2. Fever
  3. N/V
  4. Anorexia
  5. Dysuria
123
Q

Rome Criteria for Dx of constipation

A

2 or +

  1. Straining at defecation at least 25% of time
  2. Hard stools at least 25% of time
  3. Incomplete evacuation at least 25% of time
  4. <3 BM/wk
  5. Chronic constipation includes Sx for at least 12 wks in the past 12 mo
124
Q

MCC acute hepatitis?

A

Acetaminophen overdose

125
Q

Types of hepatorenal syndrome

A

Spontaneous bacterial peritonitis leading to renal failure w/ hepatic failure

  1. More serious. Progressive oliguria & doubling serum Cr in 2wks
  2. Gradual impairment of renal function that may or may not advance
126
Q

Stages of hepatic encephalopathy

A

Accumulation of nitrogenous waste products cuz liver sucks

  1. General apathy
  2. Lethargy, drowsiness, variable orientation, asterixis
  3. Stuper w/ hyperreflexia, extensor plantar reflexes
  4. Coma
127
Q

Hallmarks of liver failure

A

Hepatic encephalopathy & coagulopathy

HOTN, hypoglycemia, adrenal insufficiency

128
Q

Tx hepatic encephalopathy

A

Lactulose

129
Q

Tx liver failure

A
  1. Intubation
  2. IVF
  3. Blood products
  4. Vasopressors PRN
  5. Mannitol if cerebral edema
130
Q

Alcoholic LFT

A

AST:ALT >2

131
Q

HELLP syndrome

A

Hemolysis - elevated LFT - low platelets
Occurs w/ preeclampsia-eclampsia in late 3rd trimester or postpartum period

Tx >34 - immediate delivery

132
Q

Causes of pancreatitis

A
  1. Cholelithiasis
  2. Alcohol

Others - trauma, infection, meds, hyperparathyroidism, hyperlipidemia

133
Q

S/S pancreatitis

A
  1. N/V
  2. Epigastric pain radiates to back may be relieved by leaning forward
  3. Epigastric tenderness
  4. Diminished bowel sounds
  5. Fever
  6. Jaundice
  7. Cullens/Turners sign if retroperitoneal hemorrhage
134
Q

Dx pancreatitis

A

Use Ranson’s criteria >3

  1. Amylase
  2. Lipase**
  3. Xray - ‘cutoff’ sign
  4. US
  5. CT - best test, but not needed if no complications
135
Q

Tx pancreatitis

A
  1. NG suction
  2. Antiemetics
  3. IVF
  4. Foley cath to monitor fluids
  5. Analgesics
  6. +/- abx
136
Q

Risk factors for gall stones

A 
Forty 
Fat
Female
Fertile
Flatulent
Fair
137
Q

S/S cholecystitis

A
  1. RUQ pain radiate to scapula
  2. Post-prandial pain after eating fatty foods
  3. Murphy’s sign
  4. +/- fever
  5. Jaundice
138
Q

Dx & Tx cholecytitis

A

Labs elevated

US**

  1. NG suction
  2. Bowel rest
  3. IVF
  4. Surg. consult
139
Q

What is Charcot’s triad & when is it seen?

A
  1. RUQ pain
  2. Fever
  3. Chills & jaundice

Seen w/ ascending cholangitis
Infection of biliary system from stone in bile duct

Tx - same as cholecystitis but add abx

140
Q

What is Reynold’s pentad & when is it seen?

A
  1. RUQ pain
  2. Fever & chills
  3. Jaundice
  4. AMS
  5. HOTN

Tx - same as cholecystits but add abx

141
Q

MCC appendicitis?

A

Fecalith

142
Q

S/S appendicitis

A
  1. Gen. umbilical pain then localized to RLQ
  2. Anorexia
  3. N/V
  4. McBurney’s point
  5. Involuntary guarding & rebound tenderness
  6. Rovsing’s sign
  7. Psoas sign
  8. Obturator sign
143
Q

Dx & Tx appendicitis

A

All the dumb signs
Labs

CT w/ contrast

  1. NPO
  2. IVF
  3. Antiemetics + narcotics
  4. Abx
  5. Surgery
144
Q

MC surgical emergency in pregnant ladies?

A

Appendicitis

145
Q

Causes of AMS & Coma

A 
Alcohol
Endocrine & Environmental
Insulin & impaired glucose utilization***
Ox deprivation & opiate OD
Uremia
Trauma
Infection
Psychiatric causes & porphyria
Space occupying lesions - inc. pressure on RAS
146
Q

Causes of fixed dilated pupil

A

Temporal lobe herniation on same side or if alert - could be from drops or compression of CN III

147
Q

Causes of miosis

A 
COPS
Clonidine
Cholinergics
Opiates
Organophosphates
Phenothiazines
Pontine hemorrhage
Sedative hypnotics
Sleep
148
Q

Causes of mydriasis

A
  1. Anticholinergics

2. Sympathomimetics

149
Q

Causes of Cheyne-Stokes respirations

A

Crescendo-decrescendo pattern

  1. Bilat hemisphere dysfunction, intact brain stem
  2. Metabolic disorder
  3. Transtentorial herniation
150
Q

Causes of apneustic breathing

A

Prolonged pause after inspiration

-pontine infarct

151
Q

Causes of hyperventilation

A
  1. Met. acidosis
  2. Salicylate OD
  3. Hypoxia
  4. Hypercarbia
152
Q

S/S toxic-metabolic coma

A
  1. Lack of focal exam findings

2. Pupillary response usually preserved

153
Q

S/S supratentorial lesion coma

A
  1. Progressive hemiparesis
  2. Asymmetric strength & reflexes

Ex. Uncal herniation
Also see w/ inc. ICP - HTN & bradycardia = Cushing’s triad

154
Q

S/S infratentorial lesions - posterior fossa coma

A

Cerebellar hemorrhage or infarction may cause coma

  1. Abnormal extensor posturing
  2. Loss of pupillary reflexes
  3. Loss of EOM

Ex. pontine hemorrhage - pinpoint pupils

155
Q

S/S pseudocoma

A

Pupillary responses, EOM, muscle tone & reflexes normal

156
Q

Dx & Tx coma

A

Hx - look for reversible causes
If on meds that can check levels - check it!

CT

Tx - ABCs

157
Q

MC location of SAH HA?

A

Occipitonuchal

158
Q

Jaw claudication w/ HA?

A

Temporal arteritis

159
Q

Facial painw/ HA?

A

Sinusitis

160
Q

Vision change & eye pain w/ HA?

A

Glaucoma

161
Q

POUNDing approach to HA

A 
Pulsatile
Duration of 4-72h
Unilat
N/V
Disabling intensity

if 4/5 - most likely migraine

162
Q

HA w/ fever?

A
  1. Meningitis
  2. Sinusitis
  3. SAH
163
Q

Causes of HA w/ HIV?

A
  1. Toxoplasmosis
  2. CNS lymphoma

> 3days? Higher risk of AMS & new seizure

164
Q

Thunderclap HA?

A

SAH
CT w/o contrast or CT angio
LP if no Dx

  1. LOC
  2. Seizure
  3. Diplopia
  4. Other neuro signs

Exercise, intercourse or defecation sets it off

MCC ruptured aneurysm

165
Q

Tx SAH

A
  1. Control BP, pain & nausea
  2. Prevent vasospasm w/ Nimodipine
  3. Refer to surg.
166
Q

Risk factors of subdural hematoma

A

Remote trauma w/ HA

  1. Anticoagulants
  2. Chronic alcohol abuse
  3. Old people

Get noncontrast CT

167
Q

S/S Cerebral venous thrombosis

A
  1. HA
  2. Vomiting
  3. Seizures

Common w/ hypercoagulable state, OCs, postpartum/postop

Need magnetic resonance venogram

168
Q

S/S & Tx temporal arteritis

A
  1. HA - severe & throbbing over frontotemporal area
  2. Jaw claudication
  3. Hx of polymyalgia rheumatica
  4. +/- loss of vision
  5. High ESR

Tx - prednisone

169
Q

S/S & Tx pseudotumor cerebri

A
  1. Young Pt w/ chronic Has
  2. N/V
  3. Visual problems
  4. Papilledema
  5. Normal CT
  6. Elevated CSF pressure

Tx - Acetazolamide

170
Q

S/S internal carotid dissection & Dx

A
  1. Unilat neck pain or HA usually by eye/frontal area

Dx - angiography

171
Q

S/S & Dx vertebral artery dissection

A

Occipital or posterior neck pain

Dx - angiography

172
Q

Tx migraine

A
  1. DHE - don’t use in pregnancy, uncontrolled HTN, CAD, causes N/V
  2. Triptans
  3. Metoclopramide, prochlorperazine - dystonic rxns
  4. Ketorolac
  5. Narcotics
  6. Dexamethasone
173
Q

S/S & Tx tension HA

A
  1. Bilat, nonpulsating
  2. Not worsened by exertion
  3. No N/V

Severe HAs may cause N/V

Tx - NSAIDs/analgesics

174
Q

S/S & Tx cluster HAs

A
  1. Rare, short lived, MC men >20
  2. Severe unilat orbital, supraorbital or temporal pain lasting 15-180mins
  3. Pacing & restless
  4. Conjunctival injection, lacrimation, nasal congestion, rhinorrhea, facial swelling, miosis, ptosis

Tx

  1. Oxygen
  2. DHE
  3. Triptans
  4. Analgesics
175
Q

Tx Trigeminal neuralgia

A

Carbamazepine

MC in women

176
Q

MCC disability?

A

CVA

177
Q

Types of ischemic stroke

A
  1. Thrombotic
  2. Embolic
  3. Hypoperfusion
178
Q

Main areas affected by hypoperfusion ischemic stroke?

A

Watershed areas - periphery of major vessels

179
Q

MCC intracerebral hemorrhagic stroke?

A

Chronic HTN

MC in Asians & Blacks

180
Q

S/S middle cerebral artery stroke

A

MC type

  1. Contralat hemiparesis
  2. Facial plegia
  3. Sensory loss
  4. Homonymous hemianopsia & gaze preference toward side of infarct
  5. Face & upper extremities affected more than lower
181
Q

S/S anterior cerebral artery stroke

A
  1. Contralat sensory & motor Sx in lower extremity, sparing hands & face
  2. +/- aphasia neglect
  3. +/- incontinence
182
Q

S/S Posterior cerebral artery stroke

A
  1. Unilat HA
  2. Contralat homonymous hemianopsia
  3. Unilat cortical blindness
183
Q

S/S Vertebrobasilar stroke

A
  1. Vertigo - w/ cerebellar or brainstem signs
  2. HA
  3. Nausea
  4. Visual disturbances
  5. Oculomotor palsies
  6. Ataxia
  7. Sensory disturbance
  8. Bilat limb weakness
184
Q

S/S cerebellar stroke

A
  1. Vertigo
  2. Gait instability
  3. Ataxia
  4. Dysarthria
  5. N/V
  6. Cranial nerve abnormalities
185
Q

S/S lacunar stroke

A

Assoc. w/ HTN
Involve basal ganglia, internal capsule, thalamus & brainstem
1. Pure motor deficit of face, arm & leg
2. May be subclinical

Better prognosis

186
Q

Dx & Tx ischemic stroke

A

CT w/o contrast
May get other tests to see where emboli came from

  1. If no thrombolytics & has HTN - lower if >220/120
  2. If getting thrombolytics - lower to <185/110 w/ Labetalol, Nicardipine & Esmolol
  3. tPA w/in 3h of stroke
  4. Aspirin w/in 24-48h
187
Q

Tx TIA

A
  1. Aspirin +/- Clopidogrel
188
Q

Dx & Tx cervical artery dissection

A

MRI/MRA & CT/CTA

Tx - heparin then Coumadin

189
Q

Causes of ataxia

A

Systemic
1. Intoxication - ethanol, sedative hypnotics, phenytoin, carbamazepine, valproic acid
2. Hyponatremia
Nervous system
3. Cerebellum - hemorrhage, infarct
4. Cortex - tumor, hemorrhage, trauma, hydrocephalus
5. Subcortical - infarct, Parkinson’s
6. Spinal cord - cervical spondylosis
7. Peripheral nervous system - neuropathy

190
Q

+ Rhomberg?

A

Sensory ataxia w/ problem in posterior column, vestibular dysfunction or peripheral neuropathy

Ataxia w/ - Rhomberg?
Motor ataxia w/ problem in cerebellum

191
Q

S/S Sensory ataxia

A

Loss of proprioception

Abrupt mvmt of legs & slapping of feel w/ each step

192
Q

Apraxic gait?

A

Lost ability to initiate walking

Seen w/ nondominant hemispheric lesions

193
Q

Festinating gait?

A

Narrow based shuffling steps

Seen w/ Parkinson’s

194
Q

What is vertigo?

A

Perception of mvmt when none exists

195
Q

Causes of peripheral vertigo

A
  1. Vestibular neuritis
  2. Labyrinthitis
  3. Meniere’s disease
  4. Benign paroxysmal positional vertigo
  5. Drug induced vertigo
196
Q

Causes of central vertigo

A
  1. Acoustic schwannoma or meningioma
  2. Cerebellar pontine angle tumors
  3. Cerebellar infarct
  4. Cerebellar hemorrhage
  5. Vertebrobasilar insufficiency
197
Q

MCC vertigo in old people?

A

Benign paroxysmal positional vertigo

Do Dix-Hallpike Maneuver - Nystagmus toward affected ear for 10-40 secs

198
Q

Tx vertigo

A

Peripheral

  1. Hydration
  2. Antihistamines
  3. Anticholinergics
  4. Antiemetics
  5. Benzos
  6. Reassurance

Central
Refer to neuro!

199
Q

Tx seizures in pregnant eclampsia Pt?

A

IV magnesium

Definitive Tx - delivery

Pregnant >20wks, HTN, edema & proteinuria

200
Q

Tx peripheral neuropathies

A

Neuro!

201
Q

S/S botulism

A

Sx w/in 48h of ingestion of tainted food/wound infections/IVDU

  1. N/V/D
  2. Abd cramps
  3. Descending symmetric paralysis - CN & bulbar muscles affected first
  4. Diplopia, dysarthria, dysphagia
  5. Pupils dilated & nonreactive
202
Q

S/S botulism in baby

A
  1. Constipation
  2. Poor feeding
  3. Lethargy
  4. Weak cry
  5. “Floppy infant”
203
Q

Tx botulism

A
  1. Supportive

2. Botulinum antitoxin

204
Q

Tick paralysis S/S & Tx

A

Sx 2-6 days after tick
Ataxia of LE then UE then resp. failure

Tx - remove tick

205
Q

Giullan-barre syndrome

A

Peripheral nerve myelin sheath destruction
Subacute ascending symmetric weakness or paralysis & loss of DTRs, watch resp. function

Tx - IVIG & plasmapharesis

206
Q

Rhabdomyolysis

A

Skeletal muscle injury causing release of cell contents into plasma

Inc. PCK
Urine dipstick +blood - microscopic myoglobin

Tx - Tx cause

  1. Hydration
  2. Alkalinization of urine >6
207
Q

Myasthenia crisis

A

Extreme weakness w/ resp. failure
May be triggered by infection, surgery or tapering meds
Give Neostigmine

208
Q

Cholingergic crisis

A

Side effect of too much meds
Worsens w/ Edrophonium
May need intubation & mgmt of secretions & bronchospasm

Tx - Atropine

209
Q

Causes of neuroleptic malignant syndrome

A 
Hyperthermia, rigidity, AMS, fever 
1. Dopamine antagonists
Prolixin, Haldol, Regla, Clozapine 
2. W/D dopamine agonist
L-dopa, Bromocriptine, Amantadine
3. Dopamine depletion
Xenazine

Elevated CK, leukocytosis

Tx

  1. Cooling
  2. Fluids & alkaline diuresis to Tx rhabdo
  3. Dantrolene, Bromocriptine, Nondepolarizing NMB, Nipride
210
Q

MCC rectal bleeding?

A

Hemorrhoids

211
Q

Tx hemorrhoids

A
  1. Manual reduction if nonthrombosed, sitz-baths
  2. Topical analgesics & steroids
  3. Bulk laxatives/stool softeners, high fiber diet, fluids

Thrombosed internal - surgery
Thrombosed external - cut it out

212
Q

Location of anal fissures

A

Posterior or anterior midline

Any other area suggestive of Crohn’s, ulcerative colitis, carcinoma, infection

Usually due to passage of large hard stool or frequent diarrhea, consider child abuse

213
Q

S/S & Tx anorectal abscesses

A
  1. Constant throbbing pain, worse w/ BMs
  2. Purulent d/c
  3. Polymicrobial

Tx

  1. I&D
  2. +/- abx
214
Q

Types of rectal prolapse & Tx

A
  1. Rectal mucosa only
  2. All layers
  3. Intussusception of upper rectum through the lower

Tx

  1. Reduce w/ analgesia & sedation
  2. Can’t do it? Surg.
215
Q

MCC lower GI bleeds

A
  1. Diverticular disease
  2. Colitis
  3. Polyps
  4. CA
216
Q

MCC intestinal ischemia?

A

Ischemic colitis

217
Q

MC type of hernia?

A

Indirect inguinal hernia

Get US

218
Q

S/S, Dx & Tx mesenteric ischemia

A

Acute onset of periumbilical pain out of proportion to physical findings

Dx - CT angio
Tx - IVF, surg consult

219
Q

MCC blindness in kids?

A

Eye trauma

220
Q

S/S, Dx & Tx blowout Fx

A

From blunt force trauma

  1. Diplopia
  2. Periorbital ecchymosis & edema
  3. Anesthesia of maxillary teeth & upper lip
  4. Step off deformity over infraorbital ridge
  5. Orbital crepitus
  6. Xray - teardrop sogm

Dx - CT
Tx - Surgery

221
Q

Severe conjunctivitis in 12-24h?

A

Gonococcal

Tx

  1. Lavage mucus
  2. Ceftriaxone or Azithromycin
222
Q

Tarsal/bulbar conjunctival inclusion follicles?

A

Chlamydia conjuncitivits

Tx

  1. Tetracycline, doxy, erythromycin, azithrymycin
  2. +/- topical abx
223
Q

Subconjunctival hemorrhages w/ itchy, tearing eyes?

A

Viral conjunctivitis

Tx

  1. Artificial tears
  2. Cool compresses

Herpes? Use acyclovir

224
Q

Tx bacterial conjunctivitis

A

Broad spectrum abx

Sulfonamides, tetracycline, erythromycin

225
Q

Tx allergic conjunctivitis

A
  1. Topical antihistamines

2. Short course of topical steroids

226
Q

Dx & Tx corneal abrasion

A
  1. Fluorescein eye drops
  2. Slit lamp for intraocular FB
Tx
1. Cotton tip
2. 25 guage needle
3. Topical abx - Tobramycin, polymyxin-bacitracin ointment, erythromycin ointment
Contacts? Need Cipro
4. NSAID Diclofenac or Mydriacyl
5. Anesthetic eye drop
227
Q

S/S iritis

A

All normal eye complaints +

  1. Cells in flare in anterior chamber
  2. Ciliary flush
  3. Keratic precipitates
  4. Unilat/bilat
  5. Adhesions to the iris (posterior synchiae)
  6. Brow ache/HA
228
Q

Tx iritis

A
  1. Cycloplegics - homoatropine or atropine drops
  2. Prednisilone acetate
  3. Refer to ophthamologist
229
Q

Dx & Tx corneal ulcer

A
  1. Fluorescein eye drops
  2. Culture - bacterial & viral

If non infectious? Look at rheumatoid arthritis

Tx
1. Gentamicin or Cefazolin
Contacts? Cipro
2. Cycloplegic eye drops
3. Refer
230
Q

Corneal ulcer w/ contacts - what’s the bacteria?

A

Pseudomonas

Staph is also common

231
Q

Causes of angle closure glaucoma

A
  1. Sulfa drugs
  2. OTC decongestants
  3. Motion sickness meds
  4. Adrenergic agents
  5. Antipsychs
  6. Antidepressants
  7. Anticholinergics
232
Q

S/S Angle closure glaucoma

A

All other eye complaints:

  1. Halos around lights
  2. Pain ppt by dark conditions***
  3. Elevated IOP - maybe >60
  4. Steamy cornal edema**
  5. Mid dilated fixed pupil
  6. Shallow anterior chamber
233
Q

Tx angle closure glaucoma

A

Reduce IOP & break angle closure

  1. Beta-adrenergic drops
  2. Topical steroid drops
  3. Alpha-adrenergic agonists
  4. Carbonic anhydrase inhibitor acetazolamide
  5. Hyperosmotic agents if IOP very high
  6. Laser peripheral iridotomy to relieve pressure

EMERGENCY!

234
Q

Tx secondary angle closure glaucoma

A

From Topiramate/sulfa use

  1. D/c med
  2. Cycloplegia - atropine
  3. IV hyperosmotic agents
  4. IV steroids
  5. Refer
235
Q

MC site of bleeding for hyphema?

A

Anterior aspect of the ciliary body

236
Q

Dx & Tx hyphema

A

Hx of trauma

  1. Blood/clot in anterior chamber
  2. R/o ruptured globe
  3. Measure IOP

Tx

  1. Acetaminophen
  2. Bed rest/limited activity
  3. Elevate head
  4. Eye shield
  5. Atropine
  6. Refer
237
Q

Dx & Tx orbital cellulitis

A
  1. Hx sinus infection/surgery/insect bid/stye chalazion/infection
  2. CT w/ contrast

Tx

  1. Nasal decongestants & vasoconstrictors to drain sinuses
  2. Augmentin/Ceftriaxone
  3. I&D of abscess

Immunosuppressed? Antifungal - Amphotericin-B

238
Q

Dx & Tx preseptal cellulitis

A
  1. CT scan/MRI

Tx

  1. Antihistamines
  2. Cool compresses - insect bite
  3. Amoxicillin
239
Q

What is normal eye pressure?

A

10-22

240
Q

S/S retinal artery occlusion

A
  1. Painless, acute vision loss (over seconds)
  2. Cherry red fovea
  3. Causes irreversible cell injury in 100min
  4. HA, wt loss, jaw claudication, scalp tenderness, fever, proximal joint pain
  5. Hx Afib, endocarditis, coagulopathies, atherosclerotic disease
  6. Fell asleep on eye
241
Q

Dx retinal artery occlusion

A
  1. Whitening of retina on posterior pole
  2. Cherry red spot macula
    • APD
  4. Narrowed retinal arterioles
  5. Boxcarring/segmentation of blood columns in arterioles
  6. Find out where emboli came from
242
Q

Tx retinal artery occlusion

A
  1. Ocular massage w/ firm pressure
  2. Anterior chamber paracentesis
  3. IOP reduction - Acetazolamide/topical beta-blockers
  4. Hypervent. to induce resp. acidosis & vasodilation

Must be done 90-120min after event
REFER

243
Q

Cherry red macula?

A

Retinal artery occlusion

244
Q

Tx chemical burns

A
  1. Topical anesthesia
  2. Irrigation - check pH
  3. Artificial tears
  4. Bandage contact lens
  5. Amniotic membrane transplant
  6. Topical steroids
  7. Abx eye drops
  8. IOP>30 needs Tx
  9. Cycloplegics for pain
245
Q

What is keratitis?

A

Inflammation of the cornea

Infection/dry eyes/contacts/injury/Vit A deficiency

246
Q

S/S & Tx herpes simplex keratitis

A
  1. Unlat
  2. Mild conjunctival injection
  3. Epithelial dendrites
  4. Stromal scarring & vascularization w/ advanced disease

Tx -

  1. Cycloplegic
  2. Trifluridine
  3. Acyclovir
247
Q

S/S & Tx herpes zoster ophthalmicus

A
  1. Vesicular rash of CN 5
  2. Hutchinson’s sign - lesion on tip of nose
  3. Conjunctivitis
  4. Uveitis
  5. Glaucoma
  6. Scleritis

Tx

  1. Acyclovir
  2. Tears
248
Q

S/S & Dx & Tx Fusarium fungal keratitis

A
  1. Conjunctival injection
  2. Epithelial defect
  3. Stromal infiltration
  4. Gray-white color & rough corneal surface
  5. Irregular feathery edge infiltrates
  6. White ring on cornea
    May develop ulcer

Dx - corneal scrapings, gram & giemsa stain

Tx

  1. Natamycin or Amphotericin B
  2. Cycloplegics
249
Q

S/S & Dx & Tx bacterial keratitis

A
  1. Conjunctival hyperemia
  2. Folds in Descemet’s membrane
  3. Upper eyelid edema
  4. Posterior synchiae
  5. Focal/diffuse corneal edema
  6. Mucopurulent exudate

Dx - corneal scraping on chocolate, blood & Sabouraud agar
Smears for gram, giemsa & AF stain

Tx
1. Tobramycin alternateing w/ Cefazolin

250
Q

S/S & Dx & Tx Acanthameoba keratitis

A
  1. Conjunctival hyperemia
  2. Corneal ulcer
  3. Lid edema
  4. Corneal ring stromal infiltrate
  5. Inc. IOP
  6. Hypoyn
  7. Cataract

Dx - Corneal scraping on non-nutrient agar
Smears for gram, giemsa & calcofluor white stain (+cysts)

Tx

  1. Polyhexamethyl biguanide
  2. Propamidine isethionate
  3. Itraconazole
  4. D/c contacts
  5. Cycloplegics
251
Q

S/S & Dx & Tx Keratitis sicca

A
  1. Hyperemia
  2. Mucus
  3. High tear lakes from reflex tearing
  4. Low tear lakes
  5. Epiphoria

Dx - measure tear breakup time
measure tear production - Schirmer tear test

Tx

  1. Artificial tears
  2. Lubricating ointment at bedtime
  3. Restasis
  4. Punctal plugs
252
Q

S/S temporal arteritis

A
  1. +APD
  2. Visual field loss
  3. Pale swollen disc +/- flame hemorrhages
  4. Tender palpable temporal artery
  5. Central retinal artery occlusion
  6. Cranial nerve palsy
  7. Scalp necrosis
253
Q

Dx & Tx temporal arteritis

A

Bx

Tx -
1. Prednisone

254
Q

Which quadrant of the retina is the MC site of retinal detachment?

A

Superior temporal

255
Q

Anaphylaxis

A

IgE dependent
Anaphylactoid - does not require sensitizing exposure
Typical rxn & HOTN

  1. ABCs
  2. Epi
  3. IVF
  4. Steroids IV, antihistamines, albuterol, glucagon
256
Q

Tx urticaria

A
  1. Antihistamines (H1 +/- H2)
  2. +/- steroids

If severe - epi

257
Q

Tx angioedema

A
  1. Stop ACEi
    Not great but use:
    Epi, antihistamines & steroids

Hereditary? C1 esterase inhibitor or FFP

258
Q

What to give in anaphylaxis on beta-blockers?

A

May not respond to epi so give glucagon

259
Q

S/S back pain due to cancer

A

Usually >50
Only 1/3 w/ known CA Hx

  1. Unremitting pain
  2. Night pain
  3. Wt loss
260
Q

Straight leg raise

A

+ test = L4-L5 or L5-S1 herniated disc

Pain lifting other leg = herniated disc

Could also do by sitting knee extension

Dx w/ MRI

261
Q

S/S cauda equina

A
  1. Pain
  2. Neuro deficits - urinary incontinence, perianal sensory loss
  3. Sciatica
  4. Urinary retention
  5. Weak/stiff lower extremities
  6. Paresthesias
  7. Abnl straight leg raise

Give Dexamethasone before MRI

262
Q

S/S Vertebral osteomyelitis

A 
Sx >3mo
1. Fever
2. TTP
3. Inc. ESR, NL WBC
Xray NL until bone demineralizes 
Consult surg before abx
263
Q

S/S discitis

A
  1. Constant back pain, awaken at night - not relieved by rest/meds
  2. +/- fever
  3. +/- neuro deficits
  4. ESR inc. +/- inc. WBC
264
Q

S/S spinal epidural abscess

A
  1. Pain, fever, neuro deficits
  2. Localized pain then radicular then neuro deficits then paralysis
  3. Xrays NL
    GET MRI - emergent Surg.
265
Q

Sickle cell Pt w/ septic arthritis..what’s the bacteria & Tx?

A

Salmonella - vanco + cipro

266
Q

Tx gonococcal septic arthritis

A

3rd gen cephalosporin

Tx if suspected before cultures come back

267
Q

Tx nongonoccocal septic arthritis

A

Vanco + Ceftriaxone

Refer

268
Q

Negative birefrigence crystals on joint aspiration?

A

uric acid - gout

269
Q

Positive birefrigence crystals on joint aspiration?

A

calcium pyrophosphate - pseudogout

270
Q

Tx gout & pseudogout

A
  1. NSAIDs
  2. Colchicien
  3. Prednisone if not working

Renal failure? narcotics

271
Q

Lyme septic arthritis?

A

Mono/oligoarticular
Larger joints more - may be migratory

Doxy, Pen G, amoxicillin, Ceftriaxone

272
Q

MC locations of bursitis

A

Prepatellar or olecranon bursa

273
Q

Tx dog/cat bite

A

Pasturella

Augmentin or moxiflocin

274
Q

Flexor tenosynovitis

A

Kanavel 4 cardinal signs

  1. Percussion tenderness over flexor tendon sheath
  2. Uniform swelling
  3. Intense pain w/ passive extension
  4. Flexion posture

Surgical emergency - staph MC

Tx 1. Augmentin
2. Immobilize & elevate

275
Q

Do you drain herpetic whitlows?

A

No mammary glands

Give acyclovir - immobilize & elevate

276
Q

FInkelstein?

A

DeQuervian tenosynovitis
extensor pollicis brevis & abductor pollicis tendons

Immobilize, ROM exercises, NSAIDs

277
Q

Tx ganglion cysts

A

NSAIDs

278
Q

S/S SJS

A
  1. URI
  2. Fever
  3. HA
  4. Hematuria
  5. Diarrhea
  6. Arthralgias
  7. Rash - bullae on skin & mucus membranes, ulcers on cornea & stoma, vesicles that rupture

Tx the cause, +/- steroids

279
Q

S/S & Tx Toxic epidermal necrolysis

A

1-2 wk prodome

  1. Fever
  2. Malaise
  3. Arthralgias
  4. URI
  5. Skin tenderness, tingling/burning
  6. Erythema intially on face & genitals becoming generalized & tender & confluent rapidly then bullae
  7. Nikolsky sign

Tx

  1. Hospitalize in ICU/burn unit
  2. ABCs
  3. Elecrolyte & fluid replacement
  4. Debridement & dressing
280
Q

S/S Dx & Tx Staphylococcal scalded skin syndrome

A

Common in kids <6

  1. Painful erythema & blistering of skin w/ fever
  2. NO mucus membrane involvement
    • Nikolsky sign

Skin Bx, cultures on skin, throat & blood

Tx - IVF & abx

281
Q

What is Ramsey Hunt syndrome?

A

Herpes Zoster of CN VII - vesicles in ear canal/pinna

Hearing loss, facial paralysis, loss of taste

282
Q

Tx Rhus Dermatitis

A

Poison ivy, oak, sumac

  1. Antihistamines
  2. Oatmeal baths
  3. Topical steroids
  4. Prednisone
283
Q

S/S & Tx meningococcemia

A
  1. Pharyngitis, meningitis, bacteremia
  2. HA, fever, AMS, N/V, myalgias, stiff neck
  3. Rash - petechiae, hemorrhagic vesicles

Pt in shock & can develop DIC

Tx - abx ASAP - Ceftriaxone

284
Q

Pemphigus vulgaris & Tx

A

Old people - usually from steroids, infection, dehydration/thromboembolism

Vesicles or bullae that vary in size, blisters clear & tense then become flaccid & burst

+ Nikoslky

Tx

  1. Admit
  2. IVF & electrolytes
  3. Steroids
  4. Immunosuppressants - Azathioprine
  5. Plasmapheresis
  6. IVIG
285
Q

TM rupture

A

Only give abx if contaminated

  1. Polymyxin B
  2. Ciprodex
  3. Floxin
286
Q

Ludwig’s angina

A

Abscess of submaxillary, sulingual & submental spaces w/ tongue elevation, usually due to lower 2nd & 3rd molars

  1. Jaw swelling
  2. Stiff tongue
  3. Trismus
  4. Fever, chills
  5. Difficulty swallowing

Dx - CT

Tx - ABCs, IV abx (PCN + Flagyl), OR for drainage

287
Q

Dry socket

A

2-3 days post extraction - Severe pain d/t clot displacement of dissolving

Local/topical anesthesia, irrigate, suction fluid, pack
Abx - dental referral

288
Q

MCC death assoc. w/ ARF?

A

Sepsis & cardiopulm failure

289
Q

Dx ARF

A

Labs + Renal US

Avoid contrast dyes

290
Q

Dx & Tx Priapism

A

Color doppler US
Aspiration of dark intracevernosal blood from copus

Tx - Terbutaline SQ in deltoid
Corporal aspiration followed by irrigation
Surgery

291
Q

MC opportunistic infection in AIDS?

A

PCP

292
Q

MCC PNA AIDS Pts?

A

Strep pneumoniae

293
Q

Pt is on AZT, what should you suspect their CD4 count to be?

A

<500

294
Q

What is Brudzinski sign?

A

Hips & knees flex when you flex neck

Sign of meningitis

295
Q

What is Kernig sign?

A

Hamstrings contract when knee extended w/ hip flexed

Sign of meningitis

296
Q

MC bacterial cause of meningitis?

A

Strep pneumo

also N. meningitidis & Listeria

Tx - Ceftriaxone/Cefotaxime

297
Q

Causes of encephalitis?

A
  1. Arbovirus
  2. HSV
  3. HZV
  4. CMV
298
Q

Ring of enhancement on CT?

A

Brain abscess

299
Q

Dx rabies

A

Brain Bx

Tx - Rabies IVIG & vaccine

Emergency Medicine (5 decks)

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