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Emergency Medicine > Exam 2 > Flashcards

Exam 2 Flashcards

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1
Q

kidney stones - most common age group

A

70% of kidney stones occur between 20-50 yrs old

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2
Q

kidney stones - characteristics of pain

A

note: intra-renal stone (within the kidney) does not cause pain

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3
Q

kidney stones - types of stones

A

Calcium oxalate (80%): most common

Struvite (2-20%)

Uric Acid (6%): seen in younger women

Cystine 1(%): occurs only in patients with cystinuria

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4
Q

calcium oxalate stones - characteristic findings

A

most common

radio-opaque (can see on x-ray)

associated with hypercalcemia (high Ca++ in urine only) - primary hyperparathyroidism, malignancy, sarcoid

associated with hyperoxaluric states (high oxalates) - Crohn’s, jejunal ill bypass, high consumption of sweet tea

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5
Q

struvite stones - characteristic findings

A

cause staghorn calculi

triple phosphate stones: composed of phosphate, ammonium, magnesium

requires pH >7.2 and ammonia (caused by UTI)

proteus is most common organism

associated with foreign body (chronic catheter) or neurogenic bladder (spastic / not well controlled)

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6
Q

uric acid stones - characteristic findings

A

caused by super saturation of urine with uric acid
- gout patients get these

Radiolucent

Diet changes, allopurinol (med to dec uric acid), increased water intake prevent further stones

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7
Q

kidney stones - areas of impaction

A

Renal calyx
- stones get stuck here (cannot pass)

Ureteropelvic junction

UVJ-smallest diameter in the urinary tract
- most common site of impaction

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8
Q

kidney stone - sizes and ability to pass

A

<4 mm: 75% will pass
4 to 5 mm: 50% will pass
6 mm: 10% will pass
>10mm: require urologic intervention

Note: fully obstructed ureter can cause renal stasis

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9
Q

kidney stones - clinical presentation

A

colicy, severe pain on affected side

  • pain in waves
  • patient moves around a lot (cannot escape pain)

visceral pain caused by distention of ureter

nausea, vomiting, and pale color common

usually NOT hypotensive (shocky)

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10
Q

kidney stone location and site of pain

A

kidney = flank pain

proximal to mid ureter = flank pain, anterior abdomen to lower quadrant

UVJ (ureteral vesical junction) = labia, scrotum, groin region

Note: SUVJ and bladder stones may cause urgency, and dysuria as well as pain, or urinary retention

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11
Q

kidney stones - key history questions

A

Previous episodes of renal colic

Recurrent or Chronic UTI’s

Family history for hereditary disorders causing stones.

Immunocompromise

Solitary functioning kidney, or transplant (more concerning)

Bone pain, fractures (hyperparathyroidism = claim oxalate)

Gout, PUD peptic ulcer disease): uric acid stones

Diet, antacid use

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12
Q

suspicion of kidney stone - physical exam

A

vitals: tachycardia, elevated BP, tachypnea and diaphoresis
- hypotensive = concerned (not kidney stone)

Fever: suggests stone is infected

Flank tenderness, CVA tenderness

Abd: no point tenderness, pain not exacerbated with palpation
- must auscultate for bruits (AAA)

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13
Q

colicky flank pain - Ddx

A

AAA (often misdiagnosed as renal colic)

Renal Artery thrombosis/embolism
- seen in A fib or IV drug use

Testicular torsion

Ectopic pregnancy

Appendicitis

Cholecystitis

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14
Q

AAA - clinical presentation

A

misdiagnosed as renal colic

Caution: patients > 50 with flank pain, especially H/O tobacco, HTN, PVD (peripheral vascular disease)

A rupturing AAA may cause hydronephrosis (swelling of kidney) due to compression, and hematuria (ureteral irritation)
- white cells and red cells in urine since ureter is compressed and inflamed

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15
Q

renal artery embolus - clinical presentation

A

pain, hematuria and vomiting (intractable vomiting and pain)
- worse then a stone

risk factors: embolic disease (A-fib, PVD, IVDU)

Image: IVP (intravenous pyelogram, angiogram)
- non contrast CT will not give good info

Definitive study: arteriogram

Labs: CPK (elevated) - creatinine phosphokinase

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16
Q

ED role in renal colic

A

Relieve pain

Exclude life threatening diagnoses (AAA)

Provide appropriate disposition, follow up and instructions for returning

Not every patient needs a definitive diagnosis

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17
Q

ED treatment - renal colic

A

Hydration
- only if dehydrated or slightly hypotensive

Pain control before diagnostic tests

Analgesia: narcotics, anti-emetics (Zofran), or NSAIDS

NSAIDS: toradol (IV anti-inflammatory), ketorolac, diclofenac

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18
Q

benefits of NSAIDS to treat renal colic pain

A

non sedating
no ureteral spasm
no effect on hemodynamics

NSAIDS: toradol (IV anti-inflammatory), ketorolac, diclofenac

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19
Q

urinalysis and urine culture - renal colic

A

urinalysis and urine culture

  • 10-30% will not have microscopic hematuria
  • pyuria (WBCs) occurs due to inflammation or w/ bacteria infection
  • crystals in urine may correspond to stone type (pH>7.6 proteus infection or RTA (renal tubular acidosis)
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20
Q

microscopic hematuria - what it means in kidney stones and acute cystitis (UTI)

A

magnitude of blood in urine does not correlate with size of obstruction, pain, or significance of infection

any localized inflammation may irritate ureter (causing hematuria) - e.g. appendicitis

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21
Q

laboratory studies - renal colic

A

urinalysis and urine culture

CBC: only if concerned about infection

Chem 7: prior to contrast study

SPT (serum preg test): prior to contrast study

passed stone - sent for evaluation

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22
Q

Chem 7 laboratory test

A

electrolytes, BUN, creatinine

order before contrast study

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23
Q

imaging for suspected renal stones - 4 functions

A

non-contrast CT

1) Confirms diagnosis
2) R/O other serious disorders
3) defines site of stone
4) Detects or R/O serious complications such as obstruction

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24
Q

imaging for suspected renal stones - who should be imaged

A

first time stone producers

history of IVDU

suspicion of serious disorder

Note: frequent stone formers who are not infected and symptomatically improve, do not require a study

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25
Q

KUB - role in kidney stones

A

x-ray of kidneys, ureter, and bladder
- cannot see ureter

stones: radio-opaque will show up, but uric acid won’t (or any radiolucent stones)

limits: gas patterns, fecoliths, phleboliths, small stones (must be 2mm to be visible)
- provides no info on kidney fx

Helpful: pts w/ documented stones presenting to ER
- possibly after CT

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26
Q

Ultrasound - role in kidney stones

A

Study of choice in pregnant patients

Operator dependant, and anatomy dependent due to overlying pelvic structures

Diagnosis of stones is made through visualizing obstruction (specifically hydronephrosis)

Best at showing stones in the renal calyx and UVJ, - poor for ureteral stones

Can’t size calculi

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27
Q

IVP (intravenous pyelogram)

A

gold standard for evaluating urolithiasis and its complications
- rarely used in ED

evaluates renal fx, visualizes the entire urinary tract, and degrees of obstruction (IV contrast and sera of films)

contraindications (Chem 7):

  • allergy (0.1%)
  • pregnancy
  • DM
  • RI creatinine >1.8
  • dehydration
  • multiple myeloma
  • patients on glucophage
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28
Q

IVP disadvantages

A

May not directly visualize stone and may not accurately size the stone

Time consuming

Contrast and radiation exposure

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29
Q

helical CT (abdominal CT) - non contrast

A

standard for renal stone imaging

fast, no contrast

Identifies the stone anywhere along the GU tract

Accurately sizes the stone

Hounsfield typing may differentiate type of stone

Provides info about other intra-abdominal structures (AAA, mass)

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30
Q

helical CT (abdominal CT) disadvantages

A

Less information about the degree of obstruction as compared with IVP

May not be readily available

Radiation exposure similar to IVP

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31
Q

disposition - dx of kidney stone without infection

A

Send home w/ education

NSAIDS and narcotics
- anti-emetics

Flomax or calcium channel blocker in select patients
- helps with urinary tract spasm

Adequate hydration to produce clear urine

Strain urine until the stone passes (not always possible)

RTC: uncontrollable pain, vomiting, fever, abdominal pain

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32
Q

outpatient follow-up - kidney stones

A

Patients need a stone analysis, complete urinalysis, and blood chemistry, 24 hour urine (?)

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33
Q

guidelines to prevent kidney stones

A

Increase fluids to 3 L/day for u/o of 2 L/day

Normal calcium intake (natural, not suppl.)

Decrease sodium intake

Decrease oxalate (chocolate, nuts, black tea, dark roughage) and avoid excess vitamin C supplements

Decrease protein

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34
Q

medications to prevent kidneys stones

A

Calcium oxalate stones
- Hypercalciuria: thiazide diuretic + potassium citrate

Uric Acid stones

  • Increase urine pH to 6.5-7.0
  • Potassium Citrate
  • Allopurinol (uric acid / gout tx)
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35
Q

when to admit - renal colic / kidney stones

A

Intractable vomiting

Uncontrolled pain

Single kidney or transplanted kidney with obstruction

Concomitant UTI with obstruction

High grade obstruction or stones >8 mm (?)

Social issues

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36
Q

procedures for kidney stone removal

A

ESWL (extracorporeal shock wave therapy)
- stones crushed and passed

Percutaneous Nephrolithotomy

  • stent placed through back to drain obstruction and remove stone
  • can

Ureteroscopy
- distal ureteral stones; outpatient

Stents
- tube inserted to tx obstruction of urine flow

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37
Q

ESWL (extracorporeal shock wave therapy) - procedure for kidney stone removal

A

Done under fluoroscopy

Indicated for stones > 2cm

Stones are crushed and passed in 2 weeks

Not indicated for women of childbearing years (? Impact on ovary)

Complications:

  • hematoma formation
  • ureteral obstruction from stone fragments
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38
Q

Percutaneous Nephrolithotomy - procedure for kidney stone removal

A

Percutaneous stent placed through back under anesthesia to drain obstruction and remove renal stones > 2cm or proximal ureteral stones > 1cm

Complications:

  • bleeding
  • injury to collecting system and infection
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39
Q

Ureteroscopy - procedure for kidney stone removal

A

Indicated for distal ureteral stones

Outpatient procedure, usually requires sedation

May require placement of stent

Complications:
- ureteral stricture

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40
Q

renal stents

A

tube inserted to tx obstruction of urine flow

May become obstructed

KUB is helpful in verifying placement

Check for UTI

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41
Q

acute cystitis - presentation

A 
bladder infection (UTI)
Dysuria 		
Frequency
Urgency	
Suprapubic pain
Hematuria
Low grade fever
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42
Q

UTI - uncomplicated v. complicated

A

uncomplicated:
- lower tract sxs

complicated:

  • pyelonephritis
  • pregnancy (avoid pyelo)
  • catheter, stent, or tube in GU system
  • male (should not get UTI)
  • obstructive stone
  • hospital UTI
  • DM severe
  • treatment failure
  • anatomical abnormality
  • cancer, immune suppression
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43
Q

acute cystitis - diagnosis

A

UA dipstick:
- LE (esterase) +, nitrites +

Urine culture (micro):

  • pyuria (WBCs): >5 WBC/hpf
  • bacteruria
  • > 5 RBCs/hpf

Organisms involved: KEEP

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44
Q

acute cystitis - organisms involved

A

KEEP

Klebsiella

Enterobacter

E. coli

Pseudomonas aeroginosa/ Proteus mirabilis
- Sandy said proteus

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45
Q

suspicion of acute cystitis - Ddx

A

Non infectious dysuria

  • trauma
  • decreased estrogen in postmenopausal women, leads to atrophic vaginitis,
  • scented soaps or lotions

Kidney stone

Sterile pyuria: WBCs from another process

Unclean specimen

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46
Q

urine culture - use in acute cystitis in ER

A

gold standard for dx, but does not guide ED tx
- takes long to get results

when to send culture:

  • treatment failure
  • frequent UTIs
  • pregnancy
  • complicated UTI (pyelonephritis)
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47
Q

urine culture - what level is positive for UTI

A

Positive culture is > 105 colony forming units/hpf

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48
Q

UTI treatment

A

ABX depends on local resistance (7 day course)

  • confirm med (Janka)
  • longer course (7-10 days) in pregnancy, DM, elderly recurrences

Increase fluid

Analgesic: phenazopyridine
- stains tears (no contacts) and urine orange

Cranberry juice: may help with E. coli infection

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49
Q

pyelonephritis

A

Fever, flank pain, myalgia, anorexia, N/V, urinary sx

E. Coli 75% of time

Diagnosis:

  • CVA tenderness
  • UA: dip will show protein, LE (esterase), nitrites
  • Micro: WBC’s bacteria, WBC casts (key!)
  • Urine Cx +
  • CBC: leukocytosis with left shift
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50
Q

pyelonephritis - disposition

A

impatient:

  • child
  • pregnant
  • acutely ill

outpatient:
- can manage on oral ABX

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51
Q

pyelonephritis - treatment

A

Inpatient

  • IV abx (ampicillin and Gentamycin)
  • Consider follow up C&S (culture and sensitivity - ABX resistence)

Outpatient:

  • oral fluoroquinolone (Ciprofloxin 500 mg bid) for 14 days (+/- 400 mg IV loading dose)
  • 1gm IV Ceftriaxone q 24 hours until oral medication can be tolerated

Note:
Cranberry juice: may help with E. coli infection

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52
Q

urinary retention

A

Inability to voluntarily pass urine

Usually secondary to obstruction (BPH - benign prostate hypertrophy)

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53
Q

urinary retention - causes

A

Obstruction:
Men: BPH - prostate
Women: UTI, prolapse of bladder, rectum, or uterus

Post-op hernia surgery

young women (20-30): onset of MS

medications: anti-cholinergic medications, antihistamines, ephedrine and amphetamines

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54
Q

urinary retention - presentation

A

Straining to void
Decrease in force of urine
Interruption of urination
Sensation of incomplete emptying

Irritative sx: frequency, dysuria, urgency, nocturia

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55
Q

urinary retention - evaluation/treatment

A

Placement of foley catheter and UA

Imaging only if infection or stones suspected

Patients d/c home with foley in place, urology follow up

No abx unless high risk

Consider alpha adrenergic blockers (tamsulosin) after urologist consult (postural hypotension) 0 help w/ urinary retention

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56
Q

acute renal failure (ARF)

A

Sudden decrease in Renal function resulting in an inability to maintain fluid and electrolyte balance and excrete nitrogenous wastes

Serum creatinine most useful marker.

Failure is defined as:

  • 2-3 fold increase in serum creatinine +/-
  • decrease in urine output of < 5 cc/kg/hr for 24 hours
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57
Q

what value is concerning for low urine output

A

< 5 cc/kg/hr for 24 hours

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58
Q

acute renal failure (ARF) - characteristics and prevalence

A

Azotemia: nitrogenous waste accumulation

Uremia: symptomatic azotemia (nausea, vomiting, lethargy, altered mental state)

30% of ICU admissions have ARF

25% of hospitalized patients develop ARF

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59
Q

azotemia

A

nitrogenous waste accumulation

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60
Q

uremia

A

symptomatic azotemia - nausea, vomiting, lethargy, AMS (altered mental status)

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61
Q

acute renal failure - 3 causes

A

pre-renal (50%): sudden or severe drop in BP (shock); interruption of blood flow to kidneys
- perfusional

intra-renal (45%): direct damage to kidneys
- glomerular, tubular, interstitial

post-renal (5%): sudden obstruction of urine flow
- obstrcutive

Note: usually rule out pre and post before considering intrinsic casues

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62
Q

ARF - pre-renal causes and lab findings

A

Shock syndromes implicated: septic, cardiogenic, hemorrhagic, hypovolemic

If you can fix the shock, you fix the kidneys if caught in time

Labs (conc. urine):

  • Urine spec grav > 1.030
  • Serum Bun/Creatinine > 20
  • Urine osmolality >500
  • FENA< 1
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63
Q

ARF - renal causes and lab findings

A

Acute Tubular Necrosis (ATN) (85%)
Interstitial Nephritis (10-15%)
Glomerulonephritis (5%)

Labs (no elevated BUM/creatinine):

  • Spec grav < 1.010
  • Serum Bun/Creat <10
  • Urine osmolality <300
  • FENA >1
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64
Q

Acute Tubular Necrosis (ATN)

A

renal (within kidney) cause of ARF

acute tubular injury from ischemia or toxin

Labs:

  • BUN ratio <20:1, FENA>1%
  • Microscopic: renal tubular epithelial cells, muddy brown casts

Common drug offenders: aminoglycosides, amphotericin, contrast dye, cyclosporines

Treatment:

  • loop diuretics may help in fluid overload
  • may require dialysis
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65
Q

Interstitial Nephritis

A

renal (within kidney) cause of ARF

Causes:

  • Immune mediated response
  • Drugs: PCN, Ceph, sulfa, NSAID’s rifampin
  • Infections: Strep, RMSF(rocky mt spotted fever), CMV, Histoplasmosis
  • Immunologic: SLE, Sjogren’s, Sarcoid

Clinical: fever, azotemia (nitrogenous waste accumulation), rash, arthralgias (joint pain)

Urine micro: pyuria, esp. eosinophiluria, WBC casts, hematuria
- see eosinophils in urine since immune response

Diagnosis:
- renal biopsy

Treatment:

  • discontinue offending drug
  • self limited if found early
  • possibly dialysis
  • corticosteroids
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66
Q

Glomerulonephritis

A

renal (within kidney) cause of ARF

Immune deposition causes, vaculitis, anti glomerular basement membrane disease (goodpasture syndrome)

Strep (with edema and HNT) - can get post strep glomerulonephritis

Clinical: dependent edema and hypertension

UA shows red cell casts

Treatment:

  • high dose corticosteroids,
  • possible exchange transfusions until chemotherapy
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67
Q

ARF - diagnostics

A

Microscopic UA

BUN, Creatinine, urine sodium and FENA
- FENA helps to differentiate type of renal failure

CBC, Chem 7 ,CXR, EKG

Renal Ultrasound

  • may show obstruction upper or lower tract, small kidneys, hydronephrosis
  • CT not used as contrast may cause more injury
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68
Q

chronic renal failure - two main causes

A

2 HTN- small kidneys

#1 DM- normal sized kidneys
 - why we need aggressive control of blood sugars
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69
Q

chronic renal failure - treatment

A

Good management of underlying condition

Dialysis

Transplantation

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70
Q

ED evaluation of ARF

A

Look for life threatening complications

  • Hyperkalemia (cardiac, renal failure)
  • Pulmonary edema
  • Pericardial effusion

Physical Exam

  • Evidence of hypovolemia (tachycardia, orthostatic VS, decreased skin turgor)
  • Evidence of hypervolemia (S3, JVD, edema, rales)

Percuss the bladder (percussable with 150 ml, palpable with 500 ml urine)

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71
Q

acute abdominal pain in ED - basic facts

A

1 chief complaint in ED (~10% of all ED visits)

Second leading cause of ED lawsuits

  • Inadequate exam
  • No follow up
  • Inadequate patient instructions
  • Data misinterpretation

Often difficult to determine cause/definitive dx

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72
Q

ED approach to acute abdominal pain

A

Is the patient critically ill?

  • sever pain / rapid onset
  • abnormal VS

Do sxs fit a known disease pattern?

Special conditions:

  • cognitive impairment
  • immunocompromised

Is surgical consult needed?
- acute abd, pulsatile abd mass, shock, hemodynamic instability, rigid abd, GI bleeding

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73
Q

vital signs that are worrisome for acute abdominal pain

A

severe pain of RAPID onset

abnormal vital signs
- inc. HR, dec. BP, inc, RR< fever)

Note: BP would typically be high with pain, so if it’s low, be concerned)

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74
Q

abdominal pain - common causes (< 60 y/o)

A 
Abdominal pain, nonspecific
Appendicitis, acute
Urologic (kidney stones)
 - unique to age group
Intestinal obstruction
Biliary Disease
Trauma, abdominal
 - unique to age group
PUD, perforated viscus
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75
Q

abdominal pain - common causes (> 60 y/o)

A 
Biliary Disease
Intestinal obstruction
Abdominal pain, nonspecific
Diverticulitis
 - unique to age group
Appendicitis
PUD, perforated viscus
Malignancy
 - unique to age group
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76
Q

abdominal pain - life-threatening conditions

A

Abdominal aortic aneurysm
Thoracoabdominal aortic dissection
Ectopic pregnancy
Placental abruption

Mesenteric ischemia
Perforation of gastrointestinal tract
peptic ulcer, bowel, esophagus, or appendix
Acute bowel obstruction
Volvulus
Splenic rupture
Incarcerated hernia
Myocardial infarction

Note: top 4 will kill you if you do not dx immediately!!
- others have complications that will kill

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77
Q

visceral abdominal pain

A

direct irritation of involved organs

dull, achy, poorly localized, protracted

signs: distension, inflammation, ischemia

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78
Q

parietal (somatic) abdominal pain

A

direct irritation of parietal peritoneum of abdominal wall by gastric juice, pus, bile, urine, succus entericus, feces

steady, sharp, better localized

Peritoneal pain signs: guarding, rebound, rigidity

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79
Q

referred abdominal pain

A

Pain felt at a location distant from the diseased organ/primary stimulus

Examples:

  • AAA to lower back
  • gallbladder to shoulder
  • Ureter to groin
  • Pancreatitis to back
  • Perforated ulcer to RLQ
80
Q

misleading abdominal pain

A

from “extra-abdominal” source

Examples: Intrathoracic diseaseto upper abdomen, uremia, pneumonia, pleural effusions

81
Q

abdominal pain in elderly

A

Usually sicker than they look

  • under-report sxs
  • surgical emergencies more common
  • fever not reliable
  • do not mount same immune response

Have a low threshold for a bigger workup and to admit

82
Q

acute abdominal pain in ER - approach to patient

A

Step 1 – General survey and VS

  • Ill appearing, serious pain
  • Abnormal VS

Step 2 – History and Physical Exam

Step 3 – Diagnostic Workup

  • Labs
  • Imaging/Studies

Step 4 – Reexamine
- Do they feel better? Worse? New Sx?

Step 6 – Disposition

  • Surgical consult (does someone else need to weight in)
  • Admit to hospital
  • D/C from ED
83
Q

history for acute abdominal pain - OPQRST

A

Onset: abrupt, gradual, protracted

Provoking: eating, fatty foods, coughing, straining

Quality: dull, vague, crampy, steady, sharp, tearing

Region and Radiation: localized, diffuse, where radiates to

Severity: mild, moderate, severe

Time: duration since onset, change, constant, intermittent, prior episodes

84
Q

history for acute abdominal pain - key components

A

associated sxs:
- N/V/D, fever, sweating, dyspepsia, dysphagia, tachycardia, chest pain, SOB, LMP, dark urine, heaturia, etc.

PMH: immunocompromised, PUD, DM, CAD, A-fib, IBD, diverticulosis, etc.

PSHx: date of surgery

Medications: anticoag, antibiotic, corticosteroids, NSAIDS

Shx, FHH, allergies, providers/code status

85
Q

physical exam for acute abdominal pain - inspection

A

Distention, ascites, masses, surgical scars, ecchymosis, pulsations

  • surgical scars
  • specific findings: Grey turner’s sign, Cullen’s sign, caput medusa
86
Q

Grey Turner’s sign

A

bruising (blueish) flanks

- hemorrhagic pancreatitis or ruptured AAA (bleeding inside)

87
Q

Cullen’s sign

A

bruising around umbilicus

- hemorrhagic pancreatitis or ruptured AAA (bleeding inside)

88
Q

caput medusa

A

visible dilated abdominal venous vasculature

- sign of portal hypertension (liver failure / obstruction)

89
Q

physical exam for acute abdominal pain - auscultation

A

For bowel sounds (all 4Q)

  • High-pitched/tinkling or hyperactive: obstruction
  • Decreased or absent: ileus, narcotic use, mesenteric ischemia
  • Normal

For bruits
Renal arteries, aorta, femoral arteries

90
Q

ileus

A

obstruction due to no peristalsis

- decreased to absent bowel sounds

91
Q

physical exam for acute abdominal pain - percussion

A

Hollow organs for distention = obstruction

Peritoneal cavity for fluid wave, dullness to tympani ratio

Solid organs (Liver, spleen) for enlargement

CVA tenderness

Note: pain on percussion = worry about peritonitis

92
Q

physical exam for acute abdominal pain - palpation

A

Light and deep palpation for tenderness
- voluntary guarding, rigidity, referred tenderness, rebound tenderness

Assessment of solid organ size
- Liver, spleen, kidney
Palpation of vascular pulsations
- Aorta, femoral

93
Q

peritoneal irritation - signs on palpation of abdomen

A

rigidity, referred tenderness, rebound tenderness

94
Q

guarding

A

voluntary - person pulls away in pain

95
Q

rigidity

A

involuntary - spasm and contraction of abdominal wall

96
Q

physical exam for acute abdominal pain - rectal exam

A

Anal lesions, tenderness, masses
Detection of grossly bloody or melanotic stools, occult blood
- hypotension: be sure not bleeding from anus
Fecal impaction

97
Q

physical exam for acute abdominal pain - pelvic/GU exam

A

Note: unilateral or bilateral abdominopelvic tenderness → ectopic gestation in pregnant women with acute abdominal pain
- SERIOUS

Also palpate for masses

98
Q

diagnostic workup for acute abdominal pain - labs

A

Always get:
- CBC, BMP, LFTs, Lipase (common)/Amylase (rare), UA, urine pregnancy

Depend on Ddx: coags, cardiac enzymes, venous lactate (indicator of how sick someone is), ABG (for elderly or very sick)

Note: must get creatinine before imaging study to test kidney fx

99
Q

diagnostic workup for acute abdominal pain - imaging studies

A

plain fims: obstruction, perforation (free air)

  • abd series (upright, KUB)
  • CXR

Ultrasound: gallbladder (RUQ pain), hernias

CT abd/pelvis:

  • contrast for most things
  • no contrast for kidney stones (cannot see infection or fluid)

Angiography (CTA): mesenteric ischemia, AAA

EKG: anyone w/ epigastric pain (older, concerning)

100
Q

diagnostic workup for acute abdominal pain - imaging special considerations

A

special considerations:
- renal disfunction, pregnancy (no CT), pediatric, obese (no U/S)

See summary table

101
Q

diagnostic workup for acute abdominal pain - imaging supplemental studies

A

Serial abdominal plain films
- upper GI study (drink contrast, series of x-rays, look for obstruction)

Nuclear medicine studies
- cholescintigraphy (HIDA): gallbladder

MRCP: MRI that looks at ducts
- gallbladder and pancreas

ERCP: camera down mouth, up through common bile duct, can remove stones
- gallbladder and pancreas

102
Q

acute abdominal pain in ER - disposition (who to admit)

A

Patients with a specific diagnosis requiring admission

Cannot (reasonably) exclude potentially serious causes of abdominal pain

High-risk patients with acute abdominal pain (elderly, immune compromised, unable to communicate, cognitively impaired)

Appear ill, have intractable pain or vomiting, are unable to comply with discharge or follow-up instructions, or who lack appropriate social support

103
Q

appendicitis - general info and pathophysiology

A

most common: age 10-30

misdiagnosis remains as a leading cause of malpractice suits

Causes:

  • obstruction by lymphoid hyperplasia or fecalith (most common)
  • tumor (carcinoid - most common tumor)
  • infection (parasitic)
104
Q

appendicitis - clinical presentation

A

onset of pain before GI sxs

poorly localized initially (visceral) - localizes to RLQ

Sxs: range in magnitude; anorexia, nausea, +/- vomiting, low-grade temp / fever

PE:
Periumbilical tenderness ⟹ RLQ tenderness and guarding
McBurey’s point tenderness
Rovsing’s sign: referred pain from LLQ palpation
Obturator sign: pain w/ RLE passive hip flexion (int/ext rotation)
Psoas sign: pain w/ RLE active extension

105
Q

appendicitis - hints to perforation in hx and PE

A

Pain free interval and peritoneal signs/sx

106
Q

appendicitis - location of pain in pregnancy

A

displaced from RLQ to RUQ

107
Q

appendicitis - diagnostic work-up

A

labs:

  • Leukocytosis
  • UA: normal or RBC and WBC 2ndary to local inflammation

Studies:

  • CT (abd/pelvis) w/ contrast
  • U/S: kids and pregnant
108
Q

appendicitis - management

A

Surgical consult and admission

Preoperative management:

  • Hydration with IVF, NPO
  • IV analgesics
  • IV ABX

Definitive tx is appendectomy (laparoscopic or open technique)

Note: ruptured appendicitis will first need tx for infection (ABX) and then removal

109
Q

appendicitis - disposition (who can go home)

A

RLQ pain or tenderness w/ nomral labs, normal CT, stable VS, can eat and keep things down, pain can be controlled on PO meds, talked with surgery, able to return if sx get worse

110
Q

biliary tract disease - general info and pathophysiology

A

collection of diseases/conditions (4) involving the gallbladder and biliary tract

primarily related to gallstone disease and complications from gallstone obstruction
- gallstones remain asymptomatic in 80% of cases

pathophysiology:
obstruction or impaired gallbladder contraction → cholestasis → inflammation → infection

111
Q

biliary tract disease - risk factors

A

“F” risk factors

Female, Fertile, Forty, Fluffy (fat), Fair

112
Q

cholelithiasis

A

gallbladder stones (GS)

113
Q

biliary colic

A

intermittent obstruction of the biliary tree by stones

  • inflammation w/o obstruction
  • transient and self-limiting
  • can go home
114
Q

cholecystitis

A

gallbladder inflammation

  • Acute : obstructed cystic duct most common
  • Chronic : GB wall thickening, fibrosis, gas, no infection (no inc. WBC or fever)
  • Acalculous: geriatrics, critically ill, trauma, TPN, postpartum
  • Emphysematous: high risk gangrene, perforation
115
Q

choledocholithiasis

A

common bile duct stone - stones get stuck and and pancreatic enzymes get backed up - pancreas gets angry!

116
Q

cholangitis

A

Ascending biliary tract infection due to common bile duct obstruction
- rare but emergent (ICU)

Charcot’s triad: fever, RUQ abdominal pain, and jaundice (look under tounge and in eyes)

Reynolds pentad: Charcot’s triad + AMS and shock

117
Q

Charcot’s triad

A

fever, RUQ abdominal pain, and jaundice (look under tounge and in eyes)

118
Q

Reynolds pentad

A

Charcot’s triad + AMS (altered mental status) and shock

119
Q

biliary tract disease - clinical presentation

A

Acute RUQ pain
- referred to the R scapula or epigastrium

Crampy, colicky pain vs. moderate to severe, unremitting pain

Postprandial pain (fatty food)

Anorexia, N/V, +/- fever

Note: dark urine, light stools, jaundice/pruritus → CBD obstruction

PE:

  • RUQ tenderness
  • (+) Murphy’s sign (breath in)
  • jaundice: CBD obstruction
  • jaundice, fever, shock, AMS: cholangitis
120
Q

biliary tract disease - diagnostic workup

A

Labs:

  • CBC: normal or inc. WBC
  • CMP: normal of inc. LFTs, ALP, total bili
  • Lipase: inc. lipase (GS pancreatitis)

Imaging:
US Abdomen
- diagnostic study of choice
CT A/P if GS pancreatitis or CBD stone obstruction is suspected

Ancillary studies:
- HIDA, ERCP, MRCP

121
Q

lipase

A

tells you health of pancreas

important since pancreatic enzymes are very toxic so need to make sure this is not angry (will release if infected)

122
Q

biliary tract disease - management

A

Pain control:

  • IV Fentanyl (short-acting) or Dilaudid (longer acting)
  • NOTE: Avoid morphine (causes constriction of sphincter of Oddi)

IV Abx
- broad Spectrum ABX to cover Gram (-), Gram (+), and anaerobes

IVF, IV antiemetics

Surgery consult +/- admit to hospital
Cholecystectomy (laparoscopic vs open)
ERCP for choledocholithiasis, cholangitis
HIDA for acalculous cholecystitis

123
Q

diverticular disease - general and pathophysiology

A 
small herniations (+/- infection) through wall of colon
 - usually sigmoid colon

common, incidence inc. w/ age, 15-20% develop diverticulitis, 2/3 have uncomplicated disease (tx: high fiber diet)

Pathophysiology:
Diverticulosis: ↑ intraluminal pressures in the colon + weakening of the colon wall → diverticula

Diverticulitis:
Thickened fecal material → erosion of the diverticular wall → inflammation and microperforation → diverticulitis

Complicated diverticulitis: macroperforation, abscess, fistula, peritonitis, sepsis

124
Q

diverticula

A

small herniations through the wall of the colon

- usually sigmoid colon

125
Q

diverticulosis

A

multiple diverticula

126
Q

diverticulitis

A

inflamed or infected diverticula

127
Q

diverticular disease - clinical presentation

A

Diverticulosis:
- typically asymptomatic

Diverticulitis:

  • LLQ abdominal pain, fever
  • LLQ tenderness, tender palpable mass
  • RLQ or suprapubic pain → redundant sigmoid colon
  • NOTE: peritonitis (rebound and guarding) → perforation
  • SERIOUS
128
Q

diverticular disease - diagnostic workup

A

Labs:

  • CBC: Leukocytosis
  • BMP, LFTs, Lipase, UA: r/o other causes

Imaging:

  • CT (abd/pelvis): in ER
  • PO contrast (Gastrografin): in-patient; swallow contrast and will leak out of holes (takes 3 hrs)
129
Q

diverticular disease - management of uncomplicated diverticulitis

A

Bowel rest (liquid diet)
PO Abx x 7-14 days
- Levo/Flagyl or Augmentin
- Colonoscopy after episode subsided

Outpatient f/u with surgery if recurrent episodes

130
Q

diverticular disease - management of complicated diverticulitis

A 
Admit
Bowel rest (liquid diet)
 - NPO if obstructed (fistula, abscess)
IV Abx (broad spectrum)
Abscess – IR/CT guided drainage 
Surgical consult
 - Perforation or exploration
131
Q

intestinal obstruction - three types

A

mechanical
- usually requires surgical intervention

adynamic ileus (paralytic ileus)
 - surgical intervention uncommon

intestinal pseudo-obstruction (Ogilvie Syndrome)
- surgical intervention uncommon

132
Q

mechanical obstruction

A

physical barrier: may be complete or partial

Simple obstruction: blockage of intestinal lumen only, usually one point of blockage

Strangulated obstruction: Blockage of lumen and blood supply, usually two points of blockage (closed loop)

Usually requires surgical intervention

133
Q

adynamic ileus (paralytic ileus)

A

Neurogenic failure of peristalsis → Decreased bowel motility and muscular tone

Common: narcotic meds, post-surgery

Surgical intervention uncommon

134
Q

intestinal pseudo-obstruction (Ogilvie Syndrome)

A

Colonic dilatation without evidence of a mechanical obstruction

Ileus of large bowel, common in elderly

Surgical intervention uncommon

135
Q

most common cause of obstruction in:

  • small bowel (SBO)
  • large bowel (LBO)
  • ileus
A

SBO: adhesions (surgery)
- intussusception caused by neoplasms in adults

LBO: neoplasma
- almost never hernia or adhesions

Ileus: opiates, manipulation of bowel during surgery

136
Q

intestinal obstruction - clinical presentation

A

Intermittent, poorly localized, crampy pain

N/V, abdominal distension, decreased bowel movements and/or flatus (passing gas)

PE:

  • diffuse abdominal distention/tenderness
  • abnormal bowel sounds (high-pitched=SBO, distant or absent sounds=ileus)
  • rectal exam: fecal impaction or blood

Peritoneal signs = perforation/ischemia
- cough sign or heel bump sign

Note: more proximal the obstruction = more severe the sxs

137
Q

peritoneal signs for intestinal obstruction

A

pain with cough or heel bump = positive peritoneal signs

  • indicate perforation or ischemia
138
Q

intestinal obstruction - diagnostic workup (labs)

A

Labs: normal in early obstruction

  • CBC: Leukocytosis with a left shift
  • BMP: inc. hemoglobin and hematocrit, inc. BUM and Cr, abnormal electrolytes (vomit, dehydration)
  • venous lactate: increased in strangulation
139
Q

intestinal obstruction - diagnostic workup (imaging)

A

abdominal plain films:

  • dilated loops of bowel (air-fliud levels, constipation)
  • ileus: dilated, fluid filled loops of bowel

CT (abd/pelvis) w/ contrast

  • complete vs partial obstruction
  • strangulated vs simple
  • pneumatosis intestinalis
  • pneumoperitoneum: perforation
  • “whirl sign”: volvulus

Upper GI series w/ small bowel follow-through
- proximal dilation, collapsed distal bowel

140
Q

pneumatosis intestinalis

A

gas in the bowel wall of small or large intestine

  • seen on CT
  • air bubbles with fecal matter
  • emergent surgery!
141
Q

sigmoid volvulus

A

Hugely dilated sigmoid that almost fills the entire abdomen

Note the “coffee bean sign” also known as “bent tire tube sign”, extending from the pelvis to the diaphragm

Complete loss of haustral pattern

Disposition: GI consult for endoscopic detorsion

142
Q

intestinal obstruction - management

A

Admit to hospital, consult Surgery

  • IVF, pain control, NPO
  • NG (nasogastric) tube to intermittent suction (if vomiting)
  • IV Abx (broad spectrum)

Surgical emergencies:

  • Closed-loop obstruction
  • bowel necrosis
  • cecal volvulus

Ileus: NPO, NGT if vomiting, d/c narcotics, ambulate

Sigmoid volvulus: GI consult for endoscopic detorsion

143
Q

hernias - general information and locations

A

protrusion of any viscus from its surrounding tissue walls (i.e. through a fascial defect in abdominal wall)

Anatomical types:

  1. groin: most common
    - inguinal (indirect > direct)
    - femoral (prone to strangulation; seen in females)
  2. anterior abdominal wall: incisional, umbilical, epigastric, etc.
144
Q

inguinal hernias- direct v. indirect

A

Indirect: abdominal cavity → internal inguinal ring → inguinal canal → into the scrotum

Direct: abdominal cavity → through the posterior inguinal canal wall → inguinal canal

145
Q

types of hernias

A

Reducible: hernia contents can be displaced back to their usual position
- hernia sac is soft

Incarcerated: non-reducible by direct pressure (incarcerated tissue may be bowel, omentum, or other abdominal contents)
- hernia is firm

Strangulated: incarcerated with resulting ischemia

  • surgical emergency
  • hernia sac is hard, tender, indurated, skin changes, peritoneal signs, sepsis (+/-)
146
Q

hernia - clinical presentation

A

lump or swelling at hernia site
- size increases with exertion

may be painful/tender

sxs of bowel obstruction = strangulation

147
Q

hernia - diagnostic workup

A

Labs:
Normal unless strangulated bowel is present (↑WBC, ↑VL (venous lactate))

Imaging:

  • not always needed
  • US: identify hernia, doppler to exclude strangulation
  • CT A/P: concerned about incarceration and/or strangulation
148
Q

hernia - management

A

Reducible: reduce manually under sedation

Incarcerated: try to reduce 1-2 times; observe (abd examinations), if unable to reduce
- consult surgery

Strangulated: surgical consult for emergent repair

  • DO NOT try to reduce
  • IVF, NPO, IV ABX, IV pain control

Note: surgical repair for definitive treatment

149
Q

manual hernia reduction in ER

A

Analgesics and light sedatives administered

Patient in Trendelenburg position

Apply ice or cold compress to the area to reduce swelling/inflammation

Hernia sac is elongated and the contents are compressed in a milking fashion to ease their reduction into the abdomen

Known as “taxis procedure”

150
Q

ischemic bowel - general information and two types

A

loss of blood flow to area of bowel due to blockage in artery

mesenteric ischemia: loss of blood flow to small bowel

  • emergent
  • leads to bowel necrosis

ischemia colitis: loss of blood flow to large bowel

  • not emergent
  • does not lead to bowel necrosis
151
Q

mesenteric ischemia - general information, symptoms, treatment

A

involves superior mesenteric artery -> small bowel
- usually EMBOLIC arterial occlusion

often leads to bowel necrosis

Sxs: sudden onset of severe abd pain out of proportion to exam, ill appearing

Tx: surgical emergency, admit, treat shock
- 50% survival if dx within 24 hrs (poor prognosis)

152
Q

mesenteric ischemia - risk factors

A 
Age > 60y
A-fib
CHF
hemodialysis
hyper coagulable states
  • embolus or thrombus in superior mesenteric artery
153
Q

mesenteric ischemia - clinical presentation

A

Pain out of proportion to exam

Abdominal distension, absent BS, peritoneal signs, ill appearing

Sudden onset of severe, diffuse, mid to lower abdominal pain

Postprandial pain, gradual onset → thrombotic arterial occlusion

+/- Nausea, vomiting, diarrhea, bloody stool

154
Q

mesenteric ischemia - diagnostic workup

A

Labs:
CBC, BMP, venous lactate, ABG, coags
- ↑↑WBC, ARF, ↑lactate, metabolic acidosis

Imaging:
Angiography (CTA or MRA) is diagnostic study of choice

CT A/P + IV contrast to identify additional findings

155
Q

ischemic colitis - general information, symptoms, treatment

A

Variant of mesenteric ischemia
- usually involves the inferior mesenteric artery → COLON (splenic flexture)

S/Sx: LLQ pain and tenderness, mild/crampy abd pain, bloody diarrhea

Tx: sigmoidoscopy
- usually transient, 20% need surgical intervention

156
Q

abdominal aortic aneurysm (AAA) - general information

A

most lethal pathology if ruptures!!

Thinning of media of aorta (middle layer)

90% infrarenal
- below kidney

Infrarenal aortic diameter

  • normal: 2 cm
  • aneurysmal: > 3cm
  • need repair: > 5cm

Men:Women = 4:1

More common in age >65y

157
Q

AAA - clinical presentation

A

most are asymptomatic - become symptomatic when they leak / rupture

Severe, abrupt onset of abdominal or back pain, hypotension, syncope, AMS (lack of cerebral profusion) → Leaking or ruptured

Signs of shock, unstable hypotension

Palpable midline abdominal pulsation or mass
- tender = leaking or ruptured

Periumbilical ecchymosis (Cullen sign) or flank ecchymosis (Grey Turner sign)

158
Q

AAA - diagnostic workup

A

Labs:
CBC, BMP, type and cross (get blood ready), coags, VL (venous lactate)

Imaging:
1. plain films 9CXR, AbXR): calcified or bulging aorta

  1. abdominal U/S: ideal for unstable puts who cannot undergo CT
  2. CT A/P w. contrast: can see anatomical details of aneurysm and associated hemorrhage b/f surgery
159
Q

AAA - management

A

ALL PATIENTS with the clinical triad → emergent eval by a Vascular surgeon

IV access (2 large-bore IV’s), cardiac monitoring, supplemental O2

IVF, +/- blood products, control of VS

  • target HR 60-80 bpm
  • target BP 100-120 mmHg (permissive hypotension)

Surgical repair: transabdominal approach vs endovascular repair

160
Q

AAA - clinical triad

A

abdominal and/or back pain, a pulsatile abdominal mass, and hypotension

  • high suspicion of AAA
  • emergent eval by a xascular surgeon
161
Q

post abdominal surgery complications

A

Fever
Abdominal pain, GI complaints
Wound complications (hematomas)
Drug-therapy related complications

162
Q

causes of fever - post abdominal surgery

A

Five W’s

wind: atelectasis (24 hrs) or pneumonia (3-7d)
water: urinary tract infection (2-5 d)
wound: infection (5-10d)

Walking: deep vein thrombosis (since not walking) (4-6d)
- PE (anytime)

Wonder drugs: drug fever, thrombophlebitis (blood clots block veins), C. diff colitis

163
Q

causes of abdominal pain - post abdominal surgery

A 
Intestinal obstruction
 - adhesions (takes time to develop)
 - Ileus
Intraabdominal abscess
Anastomotic leaks
Bowel injury
164
Q

wound complication - post abdominal surgery

A

Hematomas – pain, pressure, swelling of the wound, bloody wound drainage
- usually dark blood; worry if bright red blood (something has been nicked)

Seromas – painless swelling below the wound
- gravity dependent

Infection – increasing pain, erythema, swelling, drainage, tenderness at incision site, systemic s/sx of infection

Wound dehiscence – wound ruptures along a surgical suture

165
Q

drug-therapy related complications - post abdominal surgery

A

Opiates: constipation, urinary retention

Antibiotics: C. diff colitis

166
Q

cholecystectomy - common post-surgical complications

A

Bile leak, bowel injury, pancreatitis, retained CBD (common bile duct) stones, abscess

167
Q

laparoscopic surgery -common post-surgical complications

A

Atelectasis, GI tract injuries, bowel injury

168
Q

colonoscopy - common post-surgical complications

A

Hemorrhage, perforation, retroperitoneal abscess, volvulus

169
Q

most important aspect of the evaluation of the patient with abdominal pain in the ED

A

history

  • then serial exam to evaluate how pain changes in ED
  • can give pain meds (will not mask all serious pain)
170
Q

common causes of post-surgical fevers

A

24 hours: atelectasis, necrotizing fasciitis
72 hours: PNA, UTI
5 days: DVT
7-10 days: wound infections

171
Q

approach to GI bleed

A

upper or lower?

  • ligament of Treitz separates
  • EGD v. colonoscopy (tell GI doc)

sick or not sick

MUST do rectal exam for presence of blood!!

172
Q

separation of upper and lower GI tract

A

ligament of Treitz: suspensory ligament of duodenum (b/t duodenum and jejunum)

173
Q

GI bleed fake-outs

A

Hematemesis

  • Nosebleeds
  • Dental bleeding
  • Tonsil bleeding
  • Red drinks
  • Red food

Melena

  • Charcoal
  • Pepto-bismol

Hematochezia

  • Partially digested red grapes
  • Red food (beets)
  • Vaginal bleeding
  • Gross hematuria

False + occult blood testing
- Red meat, turnips, horseradish, vitamin C

174
Q

clinical signs of liver disease

A

petechiae, jaundice, spider angiomata

175
Q

causes of dysphagia (difficulty swallowing)

A

acute:
Food Impaction
Esophageal Perforation

chronic:
Poorly controlled GERD
Esophagitis

esophageal emergencies:
Coin/button battery ingestion
Sharp Objects
Swallowed FB
Narcotic packets
176
Q

Mallory Weiss tear

A

Tear of the gastric mucosa from retching

Painless hematemesis from violent vomiting

Self limited

177
Q

Boerhaave’s

A

painful, esophageal perforation

178
Q

what foreign body in esophagus must be removed immediately

A

button batteries (can burn/perforate in 6 hours)

179
Q

acute pancreatitis - diagnosis

A

requires 2 of 3:

  • characteristic abdominal pain (severe stabbing epigastric pain or LUQ, radiates to back, begins abruptly, N/V common)
  • serum Amylase/Lipase levels > 3x normal
  • CT or US findings c/w pancreatitis (rely on labs more than imaging)
180
Q

Ranson’s Prognostic Criteria for pancreatitis

A

3 positives = severe disease (helps to determine if sending pt to ICU v. admit)

Admission:

  • Age over 55
  • Blood sugar > 200 mg/dl
  • WBC > 16,000
  • AST > 250
  • LDH > 350 IU/dl

Test other criteria 48 hours later

181
Q

anal fissure

A

tear at rectal sphincter

most common cause of rectal pain

182
Q

fecal impaction

A

Bolus of stool sits in rectal vault only allows liquid stool to pass
- commonly misdiagnosed as an obstruction by providers who don’t perform a rectal exam

Treatment:
manual disimpaction, enemas, may require sedation

183
Q

concerning complaints for vomiting

vomiting plus:
blood
abd pain
headache
female
diabetes
A

vomiting plus:

  • blood: esophageal varicies, UGI bleed
  • abd pain/distention: bowel obstruction
  • HA: migraine, inc. ICP (brain bleed)
  • Female: pregnant
  • Diabetes: DKA, diabetic gastroporesis (slowing of gut)
184
Q

cyclic vomiting syndrome

A

idiopathic disorder characterized by recurrent, stereotypical bouts of vomiting with intervening periods of normal health, without organic cause identified

185
Q

cannabis hyperemesis syndrome

A

daily vomiting with MJ use
- hot shower makes feel better (clue)

must stop using for 1 month since MJ stays in system to know if cause

186
Q

pseudomembranous colitis

A

Membrane like yellowish plaques overlay and replace necrotic intestinal mucosa
- complication of C. Diff
Progression of symptoms to include increasing pain, severe leukocytosis, lactic acidosis, hypovolemia/hypoalbuminemia

187
Q

pneumonia disposition - criteria for admitting

A 
Hypoxia
Immunocompromise
Ill Appearing
Extremes of age
Co morbid diseases
Curb-65, PSI
188
Q

CURB-65

A 
C-confusion
U-Urea >7mmol/L
R- RR > 30/minute
B-B/P <90/60
65-Age >65 years old

criteria to helpt to determine if admit for pneumonia

189
Q

Ddx for wheeze

A 
all the wheezes is not asthma:
Pneumonia
Bronchitis
Croup
COPD
CHF 
PE
Allergic reactions
FB aspiration
190
Q

when to intubate and asthmatic in ER and what sedative to use

A 
Absolute indications:
Coma and respiratory arrest
Otherwise clinical changes suggest need:
 - Increased work of breathing
 - Increased PCO2
 - decreased PO2
 - decreased mental status

Ketamine: good induction agent for asthmatics - bronchodilates

191
Q

when to admit for acute COPD exacerbations

A

Note: not every exacerbation requires hospitalization

Criteria for admission:
AMS (altered mental state)	
Co-morbid conditions
Inability to eat or sleep due to dyspnea
Inability to walk between rooms if previously mobile
Social situations
Worsening hypoxemia
No response to outpatient management
192
Q

signs of respiratory distress

A 
Tachypnea
Tripod posture
Use of accessory muscles
Diminished breath sounds
Altered mental status
Hypoventilation
Hypoxia
Physical exhaustion
193
Q

when to admit for croup

A

Persistent hypoxia
Recurrent symptoms after 3 hours
>WOB (stridor at rest, tachypnea, retractions)
>2 rounds of racemic epi

194
Q

ER levels

A 
Level 1: nearly dead
Level 2: sepsis, STEMI
Level 3:
Level 4: sprained ankle
Level 5: pain meds filled
195
Q

anatomy of penis

A

vasculature on “dorsal” side (if erect) - opposite urethra
- this is the front of the penis

Must avoid when puncturing / draining - needles in corpora cavernous (2 and 10 o’clock) - priapism

196
Q

cremasteric reflex

A

This reflex is elicited by lightly stroking or poking the superior and medial (inner) part of the thigh -normal response is an immediate contraction of the cremaster muscle that pulls up the testis ipsilaterally (on the same side of the body)

  • lost in testicular torsion
  • 30% of population just does not have normally

Emergency Medicine (3 decks)

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